Primary M

aternal Care

Primary Maternal CareAntenatal and postnatal care in the clinicPrimary Maternal Care addresses the needs of healthcare workers who provide antenatal and postnatal care, but do not conduct deliveries. It is adapted from theory chapters and skills workshops from Maternal Care. This book is ideal for midwives and doctors providing primary maternal care in level 1 district hospitals and clinics, and complements the national protocol of antenatal care in South Africa.

Chapters cover:

•antenatal care•assessment of fetal growth and

condition during pregnancy•hypertensive disorders of

pregnancy•antepartum haemorrhage•preterm labour and preterm

rupture of the membrames• the puerperium and family

planning•medical problems during

pregnancy and the puerperium

Perinatal Education Programm

e

Antenatal and postnatal care in the clinic

Primary Maternal Care

ISBN 978-1-920218-43-0

Includes practical

guides for basic

antenatal care

Learn together

“An essential tool in the initial and ongoing training and teaching of any healthcare

worker”

Miriam Adhikari on Primary Newborn Care, South African

Journal of Child Health

Developed by thePerinatal Education Programme

www.bettercare.co.za

Primary Maternal Care

Antenatal and postnatal carein the clinic

Developed by the Perinatal EducationProgramme

Very important: We have taken every care to ensure that drugdosages and related medical advice in this book are accurate.However, drug dosages can change and are updated often, soalways double-check dosages and procedures against areliable, up-to-date formulary and the given drug‘sdocumentation before administering it.

Primary Maternal Care: Antenatal and postnatal care in the clinic

First published in 2009 by Bettercare, a division of Electric Book Works (Pty)Ltd. Updated:

• 1 December 2009• 2 August 2011 (layout only)• 31 August 2014

Text © Perinatal Education Programme 2009

Illustrations by Anne Westoby

Getup © Electric Book Works 2009

ISBN (paperback): 978-1-920218-43

ISBN (PDF ebook): 978-1-920218-44-7

Excluding content explicitly credited to others, this book is published under aCreative Commons Attribution Non-Commercial No Derivatives License. Fordetails, see creativecommons.org/licenses/by-nc-nd/4.0.

This licence means you may share, copy and redistribute the material in anymedium or format under the following terms:

• Attribution — You must give appropriate credit, provide a link to the license,and indicate if changes were made. You may do so in any reasonable manner,but not in any way that suggests the licensor endorses you or your use.

• Non-Commercial — You may not use the material for commercial purposes.• No Derivatives — If you remix, transform, or build upon the material, you

may not distribute the modified material.

ContentsAcknowledgements 4

Introduction 5

1 Antenatal care 13Skills workshop 1A: General examination at the first antenatal visit 54Skills workshop 1B: Examination of the abdomen in pregnancy 61Skills workshop 1C: Vaginal examination in pregnancy 73Skills workshop 1D: Screening tests for syphilis 79Skills workshop 1E: Screening tests for HIV 85

2 Assessment of fetal growth and condition during pregnancy 89Skills workshop 2A: Routine use of the antenatal card 105

3 Hypertensive disorders of pregnancy 113Skills workshop 3A: Measuring blood pressure and proteinuria 132

4 Antepartum haemorrhage 136

5 Preterm labour and preterm rupture of the membranes 152

6 The puerperium and family planning 165

7 Medical problems during pregnancy and the puerperium 201

8 Appendix 227

Tests

1 Antenatal care 0

2 Assessment of fetal growth and condition during pregnancy 0

3 Hypertensive disorders of pregnancy 0

4 Antepartum haemorrhage 0

5 Preterm labour and preterm rupture of the membranes 0

6 The puerperium and family planning 0

7 Medical problems during pregnancy and the puerperium 0

Answers 0

AcknowledgementsPrimary Maternal Care has been edited from selected units of the MaternalCare manual of the Perinatal Education Programme. This learningprogramme for professionals is developed by the Perinatal Education Trustand funded by Eduhealthcare.

We acknowledge all the participants of the Perinatal Education Programmewho have made suggestions and offered constructive criticism. It is onlythrough constant feedback from colleagues and participants that the contentof the Perinatal Education Programme courses can be improved.

Editor-in-Chief of the Perinatal Education Programme: Prof D L WoodsEditors of Primary Maternal Care: Prof G B Theron and Prof R C PattinsonContributors to Primary Maternal Care: Prof H van C de Groot, Dr D HGreenfield, Ms H Louw, Prof G B Theron, Prof D L Woods

4 ACKNOWLEDGEMENTS

Introduction

About the Bettercare seriesBettercare publishes an innovative series of distance-learning books forhealthcare professionals, developed by the Perinatal Education Trust,Eduhealthcare, the Desmond Tutu HIV Foundation and the Desmond Tutu TBCentre, with contributions from numerous experts.

Our aim is to provide appropriate, affordable and up-to-date learning materialfor healthcare workers in under-resourced areas, so that they can managetheir own continuing education courses which will enable them to learn,practise and deliver skillful, efficient patient care.

The Bettercare series is built on the experience of the Perinatal EducationProgramme (PEP), which has provided learning opportunities to over 60 000nurses and doctors in South Africa since 1992. Many of the educationalmethods developed by PEP are now being adopted by the World HealthOrganisation (WHO).

Why decentralised learning?Continuing education for healthcare workers traditionally consists of coursesand workshops run by formal trainers at large central hospitals. Theseteaching courses are expensive to attend, often far away from the healthcareworkers’ families and places of work, and the content frequently fails toaddress the real healthcare requirements of the poor, rural communities whoface the biggest healthcare challenges.

To help solve these many problems, a self-help decentralised learning methodhas been developed which addresses the needs of professional healthcareworkers, especially those in poor, rural communities.

WHY DECENTRALISED LEARNING? 5

Books in the Bettercare seriesMaternal Care addresses all the common and important problems that occurduring pregnancy, labour, delivery and the puerperium. It covers theantenatal and postnatal care of healthy women with normal pregnancies,monitoring and managing the progress of labour, specific medical problemsduring pregnancy, labour and the puerperium, family planning andregionalised perinatal care. Skills workshops teach clinical examination inpregnancy and labour, routine screening tests, the use of an antenatal cardand partogram, measuring blood pressure, detecting proteinuria andperforming and repairing an episiotomy. Maternal Care is aimed at healthcareworkers in level 1 hospitals or clinics.

Primary Maternal Care addresses the needs of healthcare workers whoprovide antenatal and postnatal care, but do not conduct deliveries. It isadapted from theory chapters and skills workshops from Maternal Care. Thisbook is ideal for midwives and doctors providing primary maternal care inlevel 1 district hospitals and clinics, and complements the national protocol ofantenatal care in South Africa.

Intrapartum Care was developed for doctors and advanced midwives whocare for women who deliver in district hospitals. It contains theory chaptersand skills workshops adapted from the labour chapters of Maternal Care.Particular attention is given to the care of the mother, the management oflabour and monitoring the wellbeing of the fetus. Intrapartum Care waswritten to support and complement the national protocol of intrapartum carein South Africa.

Newborn Care was written for healthcare workers providing special care fornewborn infants in regional hospitals. It covers resuscitation at birth,assessing infant size and gestational age, routine care and feeding of bothnormal and high-risk infants, the prevention, diagnosis and management ofhypothermia, hypoglycaemia, jaundice, respiratory distress, infection,trauma, bleeding and congenital abnormalities, as well as communicationwith parents. Skills workshops address resuscitation, size measurement,history, examination and clinical notes, nasogastric feeds, intravenousinfusions, use of incubators, measuring blood glucose concentration,

6 INTRODUCTION

insertion of an umbilical vein catheter, phototherapy, apnoea monitors andoxygen therapy.

Primary Newborn Care was written specifically for nurses and doctorswho provide primary care for newborn infants in level 1 clinics and hospitals.Primary Newborn Care addresses the care of infants at birth, care of normalinfants, care of low-birth-weight infants, neonatal emergencies, and commonminor problems in newborn infants.

Mother and Baby Friendly Care describes gentler, kinder, evidence-basedways of caring for women during pregnancy, labour and delivery. It alsopresents improved methods of providing infant care with an emphasis onkangaroo mother care and exclusive breastfeeding.

Saving Mothers and Babies was developed in response to the highmaternal and perinatal mortality rates found in most developing countries.Learning material used in this book is based on the results of the annualconfidential enquiries into maternal deaths and the Saving Mothers andSaving Babies reports published in South Africa. It addresses the basicprinciples of mortality audit, maternal mortality, perinatal mortality,managing mortality meetings and ways of reducing maternal and perinatalmortality rates. This book should be used together with the Perinatal ProblemIdentification Programme (PPIP).

Birth Defects was written for healthcare workers who look after individualswith birth defects, their families, and women who are at increased risk ofgiving birth to an infant with a birth defect. Special attention is given tomodes of inheritance, medical genetic counselling, and birth defects due tochromosomal abnormalities, single gene defects, teratogens and multifactorialinheritance. This book is being used in the Genetics Education Programmewhich trains healthcare workers in genetic counselling in South Africa.

Perinatal HIV enables midwives, nurses and doctors to care for pregnantwomen and their infants in communities where HIV infection is common.Special emphasis has been placed on the prevention of mother-to-infanttransmission of HIV. It covers the basics of HIV infection and screening,antenatal and intrapartum care of women with HIV infection, care of HIV-exposed newborn infants, and parent counselling.

Childhood HIV enables nurses and doctors to care for children with HIVinfection. It addresses an introduction to HIV in children, the clinical and

BOOKS IN THE BETTERCARE SERIES 7

immunological diagnosis of HIV infection, management of children with andwithout antiretroviral treatment, antiretroviral drugs, opportunistic infectionsand end-of-life care.

Childhood TB was written to enable healthcare workers to learn about theprimary care of children with tuberculosis. The book covers an introductionto TB infection, and the clinical presentation, diagnosis, management andprevention of tuberculosis in children and HIV/TB co-infection. Childhood TBwas developed by paediatricians with wide experience in the care of childrenwith tuberculosis, under the auspices of the Desmond Tutu TuberculosisCentre at the University of Stellenbosch.

Child Healthcare addresses all the common and important clinical problemsin children, including immunisation, history and examination, growth andnutrition, acute and chronic infections, parasites, skin conditions, anddifficulties in the home and society. Child Healthcare was developed for use inprimary care settings.

Adult HIV covers an introduction to HIV infection, management of HIV-infected adults at primary-care clinics, preparing patients for antiretroviral(ARV) treatment, ARV drugs, starting and maintaining patients on ARVtreatment and an approach to opportunistic infections. Adult HIV wasdeveloped by doctors and nurses with wide experience in the care of adultswith HIV, under the auspices of the Desmond Tutu HIV Foundation at theUniversity of Cape Town.

Well Women was written for primary health workers who manage theeveryday health needs of women. It covers reproductive health, familyplanning and infertility, common genital infections, vaginal bleeding, and theabuse of women.

Breast Care was written for nurses and doctors who manage the healthneeds of women from childhood to old age. It covers the assessment andmanagement of benign breast conditions, breast cancer and palliative care.

Infection Prevention and Control was written for nurses, doctors, andhealth administrators working in the field of infection prevention andcontrol, particularly in resource-limited settings. It includes chapters on IPCprogrammes, risk management, health facility design, outbreak surveillanceand antimicrobial stewardship.

8 INTRODUCTION

Format of the courses1. ObjectivesThe learning objectives are clearly stated at the start of each chapter. Theyhelp the participant to identify and understand the important lessons to belearned.

2. Pre- and post-testsThere is a multiple-choice test of 20 questions for each chapter at the end ofthe book. Participants are encouraged to take a pre-test before starting eachchapter, to benchmark their current knowledge, and a post-test after eachchapter, to assess what they have learned. Self-assessment allows participantsto monitor their own progress through the course.

3. Question-and-answer formatTheoretical knowledge is presented in a question-and-answer format, whichencourages the learner to actively participate in the learning process. In thisway, the participant is led step by step through the definitions, causes,diagnosis, prevention, dangers and management of a particular problem.

Participants should cover the answer for a few minutes with a piece of paperwhile thinking about the correct reply to each question. This method helpslearning.

Simplified flow diagrams are also used, where necessary, to indicate thecorrect approach to diagnosing or managing a particular problem. Eachquestion is written in bold, like this, and is identified with the number of thechapter, followed by the number of the question, e.g. 5-23.

4. Important lessons

Important practical lessons are emphasised by placing them ina box like this.

FORMAT OF THE COURSES 9

5. NotesNOTE

Additional, non-essential information is provided for interest and given in noteslike this. These facts are not used in the case studies or included in the multiple-choice questions.

6. Case studiesEach chapter closes with a few case studies which encourage the participantto consolidate and apply what was learned earlier in the chapter. Thesestudies give the participant an opportunity to see the problem as it usuallypresents itself in the clinic or hospital. The participant should attempt toanswer each question in the case study before reading the correct answer.

7. Practical trainingCertain chapters contain skills workshops, which need to be practised by theparticipants (preferably in groups). The skills workshops, which are oftenillustrated with line drawings, list essential equipment and present step-by-step instructions on how to perform each task. If participants aren’t familiarwith a practical skill, they are encouraged to ask an appropriate medical ornursing colleague to demonstrate the clinical skill to them. In this way, seniorpersonnel are encouraged to share their skills with their colleagues.

8. Final examinationOn completion of each course, participants can take a 75-question multiple-choice examination.

All the exam questions will be taken from the multiple-choice tests from thebook. The content of the skills workshops will not be included in theexamination.

Participants need to achieve at least 80% in the examination in order tosuccessfully complete the course. Successful candidates will be emailed acertificate which states that they have successfully completed that course.Bettercare courses are not yet accredited for nurses, but South Africandoctors can earn CPD points on the successful completion of an examination.

10 INTRODUCTION

ContributorsThe developers of our learning materials are a multi-disciplinary team ofnurses, midwives, obstetricians, neonatologists, and general paediatricians.The development and review of all course material is overseen by the Editor-in-Chief, emeritus Professor Dave Woods, a previous head of neonatalmedicine at the University of Cape Town who now consults to UNICEF andthe WHO.

Perinatal Education TrustBooks developed by the Perinatal Education Programme are provided ascheaply as possible. Writing and updating the programme is both funded andmanaged on a non-profit basis by the Perinatal Education Trust.

EduhealthcareEduhealthcare is a non-profit organisation based in South Africa. It aims toimprove health and wellbeing, especially in poor communities, throughaffordable education for healthcare workers. To this end it provides financialsupport for the development and publishing of the Bettercare series.

The Desmond Tutu HIV FoundationThe Desmond Tutu HIV Foundation at the University of Cape Town, SouthAfrica, is a centre of excellence in HIV medicine, building capacity throughtraining and enhancing knowledge through research.

The Desmond Tutu Tuberculosis CentreThe Desmond Tutu Tuberculosis Centre at Stellenbosch University, SouthAfrica, strives to improve the health of vulnerable groups through theeducation of healthcare workers and community members, and byinfluencing policy based on research into the epidemiology of childhoodtuberculosis, multi-drug-resistant tuberculosis, HIV/TB co-infection andpreventing the spread of TB and HIV in southern Africa.

CONTRIBUTORS 11

Updating the course materialBettercare learning materials are regularly updated to keep up withdevelopments and changes in healthcare protocols. Course participants canmake important contributions to the continual improvement of Bettercarebooks by reporting factual or language errors, by identifying sections that aredifficult to understand, and by suggesting additions or improvements to thecontents. Details of alternative or better forms of management would beparticularly appreciated. Please send any comments or suggestions to theEditor-in-Chief, Professor Dave Woods.

Contact informationBettercare

• Website: www.bettercare.co.za• Email: info@bettercare.co.za• Phone: 076 657 0353• Fax: 086 219 8093

Perinatal Education Programme• Editor-in-Chief: Professor Dave Woods• Website: www.pepcourse.co.za• Email: pepcourse@mweb.co.za• Phone/fax: 021 786 5369• Post: Perinatal Education Programme,• 70 Dorries Drive, Simon’s Town, 7975

ExamsEmail: exams@bettercare.co.za

12 INTRODUCTION

1Antenatal careBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• List the goals of good antenatal care.• Diagnose pregnancy.• Know what history should be taken and examination done at the first visit.• Determine the duration of pregnancy.• List and assess the results of the side room and screening tests needed at the

first visit.• Identify low, intermediate and high-risk pregnancies.• Plan and provide antenatal care that is problem oriented.• List what specific complications to look for at 28, 34 and 41 weeks.• Provide health information during antenatal visits.• Manage women with HIV infection.

Goals of good antenatal care1-1 What are the aims and principles of good antenatal care?The aims of good antenatal care are to ensure that pregnancy causes no harmto the mother and to keep the fetus healthy during the antenatal period. Inaddition, the opportunity must be taken to provide health education. Theseaims can usually be achieved by the following:

GOALS OF GOOD ANTENATAL CARE 13

1. Antenatal care must follow a definite plan.2. Antenatal care must be problem oriented.3. Possible complications and risk factors that may occur at a particular

gestational age must be looked for at these visits.4. The fetal condition must be repeatedly assessed.5. Health care education must be provided.

All information relating to the pregnancy must be entered on a patient-heldantenatal card. The antenatal card can also serve as a referral letter if apatient is referred to the next level of care and therefore serves as a linkbetween the different levels of care as well as the antenatal clinic and labourward.

The antenatal card is an important source of informationduring the antenatal period and labour.

Diagnosing pregnancy1-2 How can you confirm that a patient is pregnant?The common symptoms of pregnancy are amenorrhoea (no menstruation),nausea, breast tenderness and urinary frequency. If the history suggests thata patient is pregnant, the diagnosis is easily confirmed by testing the urinewith a standard pregnancy test. The test becomes positive by the time thefirst menstrual period is missed.

A positive pregnancy test is produced by both an intra-uterine and an extra-uterine pregnancy. Therefore, it is important to establish whether thepregnancy is intra-uterine or not.

Confirm that the patient is pregnant before beginningantenatal care.

1-3 How do you diagnose an intra-uterine pregnancy?The characteristics of an intra-uterine pregnancy are:

14 ANTENATAL CARE

1. The size of the uterus is appropriate for the duration of pregnancy.2. There is no lower abdominal pain or vaginal bleeding.3. There is no tenderness of the lower abdomen.

1-4 How do you diagnose an extra-uterine pregnancy?The characteristics of an extra-uterine (ectopic) pregnancy are:

1. The uterus is smaller than expected for the duration of pregnancy.2. Lower abdominal pain and vaginal bleeding are usually present.3. Tenderness over the lower abdomen is usually present.

The first antenatal visitThis visit is usually the patient’s first contact with the medical services duringher pregnancy. She must be treated with kindness and understanding in orderto gain her confidence and to ensure her future co-operation and regularattendance. This opportunity must be taken to book the patient for antenatalcare and, thereby, ensure the early detection and management of treatablecomplications.

1-5 At what gestational age should a patient first attend anantenatal clinic?As early as possible, preferably when the second menstrual period has beenmissed, i.e. at a gestational age (duration of pregnancy) of 8 weeks. Note thatfor practical reasons the gestational age is measured from the first day of thelast normal menstrual period. Antenatal care should start at the time that thepregnancy is confirmed.

It is important that all pregnant women book as early aspossible.

1-6 What are the aims of the first antenatal visit?1. A full history must be taken.2. A full physical examination must be done.3. The duration of pregnancy must be established.

THE FIRST ANTENATAL VISIT 15

4. Important screening tests must be done.5. Some high-risk patients can be identified.

1-7 What history should be taken?A full history, containing the following:

1. The previous obstetric history.2. The present obstetric history.3. A medical history.4. HIV status.5. History of medication and allergies.6. A surgical history.7. A family history.8. The social circumstances of the patient.

1-8 What is important in the previous obstetric history?1. Establish the number of pregnancies (gravidity), the number of previous

pregnancies reaching viability (parity) and the number of miscarriages andectopic pregnancies that the patient may have had. This information mayreveal the following important factors:

◦ Grande multiparity (i.e. 5 or more pregnancies which have reached viability).◦ Miscarriages: 3 or more successive first trimester miscarriages suggest a

possible genetic abnormality in the father or mother. A previous midtrimestermiscarriage suggests a possible incompetent internal cervical os.

◦ Ectopic pregnancy: ensure that the present pregnancy is intra-uterine.◦ Multiple pregnancy: non-identical twins tend to recur.

2. The birth weight, gestational age and method of delivery of each previousinfant as well as of previous perinatal deaths are important:

◦ Previous low birth weight infants or spontaneous preterm labours tend torecur.

◦ Previous large infants (4 kg or more) suggest maternal diabetes.◦ The type of previous delivery is also important: a forceps delivery or vacuum

extraction may suggest that a degree of cephalopelvic disproportion had beenpresent. If the patient had a previous caesarean section, the indication for thecaesarean section must be determined.

16 ANTENATAL CARE

◦ The type of incision in the uterus is also important (this information must beobtained from the patient’s folder) as only patients with a transverse lowersegment incision should be considered for a possible vaginal delivery.

◦ Having had one or more perinatal deaths places the patient at high risk offurther perinatal deaths. Therefore, every effort must be made to find out thecause of any previous deaths. If no cause can be found, then the risk of arecurrence of perinatal death is even higher.

3. Previous complications of pregnancy or labour:◦ In the antenatal period, e.g. pre-eclampsia, preterm labour, diabetes, and

antepartum haemorrhage. Patients who develop pre-eclampsia before 34weeks gestation have a greater risk of pre-eclampsia in further pregnancies.

◦ First stage of labour, e.g. a long labour.◦ Second stage of labour, e.g. impacted shoulders.◦ Third stage of labour, e.g. a retained placenta or a postpartum haemorrhage.

Complications in previous pregnancies tend to recur insubsequent pregnancies. Therefore, patients with a previousperinatal death are at high risk of another perinatal death,while patients with a previous spontaneous preterm labour areat high risk of preterm labour in their next pregnancy.

1-9 What information should be asked for when taking the presentobstetric history?

1. The first day of the last normal menstrual period must be determined asaccurately as possible.

2. Any medical or obstetric problems which the patient has had since the startof this pregnancy, for example:

◦ Pyrexial illnesses (such as influenza) with or without skin rashes.◦ Symptoms of a urinary tract infection.◦ Any vaginal bleeding.

3. Attention must be given to minor symptoms which the patient mayexperience during her present pregnancy, for example:

◦ Nausea and vomiting.◦ Heartburn.

THE FIRST ANTENATAL VISIT 17

◦ Constipation.◦ Oedema of the ankles and hands.

4. Is the pregnancy planned and wanted, and was there a period of infertilitybefore she became pregnant?

5. If the patient is already in the third trimester of her pregnancy, attentionmust be given to the condition of the fetus.

1-10 What important facts must be considered when determiningthe date of the last menstrual period?

1. The date should be used to measure the duration of pregnancy only if thepatient had a regular menstrual cycle.

2. Were the date of onset and the duration of the last period normal? If the lastperiod was shorter in duration and earlier in onset than usual, it may havebeen an implantation bleed. Then the previous period must be used todetermine the duration of pregnancy.

3. Patients on oral or injectable contraception must have menstruatedspontaneously after stopping contraception, otherwise the date of the lastperiod should not be used to measure the duration of pregnancy.

1-11 Why is the medical history important?Some medical conditions may become worse during pregnancy, e.g. a patientwith heart valve disease may go into cardiac failure while a hypertensivepatient is at high risk of developing pre-eclampsia.

Ask the patient if she has had any of the following:

1. Hypertension.2. Diabetes mellitus.3. Rheumatic or other heart disease.4. Epilepsy.5. Asthma.6. Tuberculosis.7. Psychiatric illness.8. Any other major illness.

It is important to ask whether the patient knows her HIV status. If she had anHIV test, both the date and result need to be noted. If she is HIV positive,record whether she is on antiretroviral (ARV) treatment (ART) and which

18 ANTENATAL CARE

drugs she is taking. If she is not on ARV treatment, note whether she knowsher CD4 count and when it was done.

1-12 Why is it important to ask about any medication taken and ahistory of allergy?

1. Ask about the regular use of any medication. This is often a pointer to anillness not mentioned in the medical history.

2. Certain drugs can be teratogenic (damage the fetus) during the first trimesterof pregnancy, e.g. retinoids which are used for acne and efavirenz (Stocrin)used in antiretroviral treatment.

3. Some drugs can be dangerous to the fetus if they are taken close to term, e.g.Warfarin.

4. Allergies are also important and the patient must be specifically asked if sheis allergic to penicillin.

1-13 What previous operations may be important?1. Operations on the urogenital tract, e.g. caesarean section, myomectomy, a

cone biopsy of the cervix, operations for stress incontinence andvesicovaginal fistula repair.

2. Cardiac surgery, e.g. heart valve replacement.

1-14 Why is the family history important?Close family members with a condition such as diabetes, multiple pregnancy,bleeding tendencies or mental retardation increases the risk of theseconditions in the patient and her unborn infant. Some birth defects areinherited.

THE FIRST ANTENATAL VISIT 19

1-15 Why is information about the patient’s social circumstancesvery important?

1. Ask if the woman smokes cigarettes or drinks alcohol. Smoking may causeintra-uterine growth restriction while alcohol may cause both intra-uterinegrowth restriction and congenital malformations.

2. The unmarried mother may need help to assist her to plan for the care of herinfant.

3. Unemployment, poor housing and overcrowding increase the risk oftuberculosis, malnutrition and intra-uterine growth restriction. Patients livingin poor social conditions need special support and help.

1-16 To which systems must you pay particular attention whendoing a physical examination?

1. The general appearance of the patient is of great importance as it can indicatewhether or not she is in good health.

2. A woman’s height and weight may reflect her past and present nutritionalstatus.

3. In addition the following systems or organs must be carefully examined:◦ The thyroid gland.◦ The breasts.◦ Lymph nodes in the neck, axillae (armpits) and inguinal areas.◦ The respiratory system.◦ The cardiovascular system.◦ The abdomen.◦ Both external and internal genitalia.

1-17 What is important in the examination of the thyroid gland?1. A thyroid gland which is visibly enlarged is possibly abnormal and must be

examined by a doctor.2. A thyroid gland which on palpation is only slightly, diffusely enlarged is

normal in pregnancy.3. An obviously enlarged gland, a single palpable nodule or a nodular goitre is

abnormal and needs further investigation.

20 ANTENATAL CARE

1-18 What is important in the examination of the breasts?1. Inverted or flat nipples must be diagnosed and treated so that the patient will

be more likely to breastfeed successfully.2. A breast lump or a blood-stained discharge from the nipple must be

investigated further as it may indicate the presence of a tumour.3. Whenever possible, patients should be advised and encouraged to breastfeed.

Teaching the advantages of breastfeeding is an essential part of antenatal careand must be emphasised in the following groups of women:

◦ HIV-negative women.◦ Women with unknown HIV status.◦ HIV-positive women who have elected to exclusively breastfeed.

1-19 What is important in the examination of the respiratory andcardiovascular systems?

1. Look for any signs which suggest that the patient has difficulty breathing(dyspnoea).

2. The blood pressure must be measured and the pulse rate counted.

1-20 How do you examine the abdomen at the booking visit?1. The abdomen is palpated for enlarged organs or masses.2. The height of the fundus above the symphysis pubis is measured.

1-21 What must be looked for when the external and internalgenitalia are examined?

1. Signs of sexually transmitted diseases which may present as single ormultiple ulcers, a purulent discharge or enlarged inguinal lymph nodes.

2. Carcinoma of the cervix is the commonest form of cancer in mostcommunities. Advanced stages of this disease present as a wart-like growthor an ulcer on the cervix. A cervix which looks normal does not exclude thepossibility of an early cervical carcinoma.

THE FIRST ANTENATAL VISIT 21

1-22 When must a cervical smear be taken when examining theinternal genitalia (gynaecological examination)?

1. All patients aged 30 years or more who have not previously had a cervicalsmear that was reported as normal.

2. All patients who have previously had a cervical smear that was reported asabnormal.

3. All patients who have a cervix that looks abnormal.4. All HIV-positive patients who did not have a cervical smear reported as

normal within the last year.

A cervix that looks normal may have an early carcinoma.

Determining the duration of pregnancyAll available information is now used to assess the duration of pregnancy asaccurately as possible:

1. Last normal menstrual period.2. Size of the uterus on bimanual or abdominal examination up to 18 weeks.3. Height of fundus at or after 18 weeks.4. The result of an ultrasound examination (ultrasonology).

An accurate assessment of the duration of pregnancy is of greatimportance, especially if the woman develops complicationslater in her pregnancy.

1-23 When is the duration of pregnancy calculated from the lastnormal menstrual period?When there is certainty about the accuracy of the dates of the last, normalmenstrual period. The duration of pregnancy is then calculated from the firstday of that period.

22 ANTENATAL CARE

1-24 How does the size of the uterus indicate the duration ofpregnancy?

1. Up to 12 weeks the size of the uterus, assessed by bimanual examination, is areasonably accurate method of determining the duration of pregnancy.Therefore, if there is uncertainty about the duration of pregnancy before 12weeks the patient should be referred for a bimanual examination.

2. From 13 to 17 weeks, when the fundus of the uterus is still below theumbilicus, the abdominal examination is the most accurate method ofdetermining the duration of pregnancy.

3. From 18 weeks, the symphysis-fundus height measurement is the moreaccurate method.

1-25 How should you determine the duration of pregnancy if theuterine size and the menstrual dates do not indicate the samegestational age?

1. If the fundus is below the umbilicus (in other words, the patient is less than22 weeks pregnant):

◦ If the dates and the uterine size differ by 3 weeks or more, the uterine sizeshould be considered as the more accurate indicator of the duration ofpregnancy.

◦ If the dates and the uterine size differ by less than 3 weeks, the dates are morelikely to be correct.

2. If the fundus is at or above the umbilicus (in other words, the patient is 22weeks or more pregnant):

◦ If the dates and the uterine size differ by 4 weeks or more, the uterine sizeshould be considered as the more accurate indicator of the duration ofpregnancy.

◦ If the dates and the uterine size differ by less than 4 weeks, the dates are morelikely to be correct.

1-26 How should you use the symphysis-fundus heightmeasurement to determine the duration of pregnancy?From 18 weeks gestation, the symphysis-fundus (S-F) height measurement incm is plotted on the 50th centile of the S-F growth curve to determine theduration of pregnancy. For example, a S-F measurement of 26 cm correspondsto a gestation of 27 weeks.

DETERMINING THE DURATION OF PREGNANCY 23

A difference between the gestational age according to themenstrual dates and the size of the uterus is usually the resultof incorrect dates.

1-27 What conditions other than incorrect menstrual dates cause adifference between the duration of pregnancy calculated frommenstrual dates and the size of the uterus?

1. A uterus bigger than dates suggests:◦ Multiple pregnancy.◦ Polyhydramnios.◦ A fetus which is large for the gestational age.◦ Diabetes mellitus.

2. A uterus smaller than dates suggests:◦ Intra-uterine growth restriction.◦ Oligohydramnios.◦ Intra-uterine death.◦ Rupture of the membranes.

Side room and special screeninginvestigations1-28 Which side room screening investigations must be doneroutinely?

1. A haemoglobin estimation at the first antenatal visit and again at 28 and 36weeks.

2. A urine test for protein and glucose is done at every visit.

24 ANTENATAL CARE

1-29 What special investigations should be done routinely?1. A laboratory serological screening test for syphilis such as a VDRL, RPR or

TPHA test. An on-site RPR card test or syphilis rapid test can be performed inthe clinic, if a laboratory is not within easy reach of the hospital or clinic.

2. Determining whether the patient’s blood group is Rh positive or negative. ARh card test can be done in the clinic.

3. A rapid HIV screening test after health worker initiated counselling andpreferably after written consent.

4. A smear of the cervix for cytology if it is indicated.5. If possible, all patients should have a midstream urine specimen examined for

asymptomatic bacteriuria. The best test is bacterial culture of the urine.6. Where possible, an ultrasound examination when the patient is 18–22 weeks

pregnant can be arranged

NOTEUltrasound screening at 11 to 13 weeks for nuchal thickness, or the triple test, isvery useful in screening for Down syndrome and other chromosomalabnormalities. Written informed consent for HIV testing is not a legal requirementin South Africa, but recommended as good practice.

1-30 Is it necessary to do an ultrasound examination on all patientswho book early enough for antenatal care?With well-trained ultrasonographers and adequate ultrasound equipment, itis of great value to:

1. Accurately determine the gestational age if the first ultrasound examinationis done at 24 weeks or less. With uncertain gestational age the fundal heightwill measure less than 24cm.

2. Diagnose multiple pregnancies early.3. Identify the site of the placenta.4. Diagnose severe congenital abnormalities.

If it is not possible to provide ultrasound examinations to all antenatalpatients before 24 weeks gestation, the following groups of patients maybenefit greatly from the additional information which may be obtained:

1. Patients with a gestational age of 14 to 16 weeks:◦ Patients aged 37 years or more because of their increased risk of having a

fetus with a chromosomal abnormality (especially Down syndrome). A

SIDE ROOM AND SPECIAL SCREENING INVESTIGATIONS 25

patient who would agree to termination of pregnancy if the fetus wasabnormal, should be referred for amniocentesis.

◦ Patients with a previous history or family history of congenital abnormalities.The nearest hospital with a genetic service should be contacted to determinethe need for amniocentesis.

2. Patients with a gestational age of 18 to 22 weeks:◦ Patients needing elective delivery (e.g. those with 2 previous caesarean

sections, a previous perinatal death, a previous vertical uterine incision orhysterotomy, and diabetes).

◦ Gross obesity when it is often difficult to determine the duration ofpregnancy.

◦ Previous severe pre-eclampsia or preterm labour before 34 weeks. As there isa high risk of recurrence of either complication, accurate determination of theduration of pregnancy greatly helps in the management of these patients.

◦ Rhesus sensitisation where accurate determination of the duration ofpregnancy helps in the management of the patient.

An ultrasound examination done after 24 weeks is toounreliable to be used to estimate the duration of pregnancy.

1-31 What is the assessment of risk after booking the patient?Once the patient has been booked for antenatal care, it must be assessedwhether she or her fetus have complications or risk factors present, as thiswill decide when she should be seen again. At the first visit some patientsshould already be placed in a high-risk category.

1-32 If no risk factors are found at the booking visit, when shouldthe patient be seen again?She should be seen again when the results of the screening tests are available,preferably 2weeks after the booking visit. However, if no risk factors werenoted and the screening tests done as rapid tests were normal the second visitis omitted.

26 ANTENATAL CARE

1-33 If there are risk factors noted at the booking visit, when shouldthe patient be seen again?

1. A patient with an underlying illness must be admitted for furtherinvestigation and treatment.

2. A patient with a risk factor is followed up sooner if necessary:◦ The management of a patient with chronic hypertension would be planned

and the patient would be seen a week later.◦ An HIV-positive patient with an unknown CD4 count must be seen a week

later to assess the state of her immune system.

1-34 How should you list risk factors?All risk factors must be entered on the problem list on the back of theantenatal card. The gestational age when management is needed should beentered opposite the gestational age at the top of the card, e.g. vaginalexamination must be done at each visit from 26 to 32 weeks if there is a riskof preterm labour.

The clinic checklist (Figure 1-3) for the first visit could now be completed. Ifall the open blocks for the first visit can be ticked off, the visit is completedand all important points have been addressed. The checklist should again beused during further visits to make sure that all problems have beenconsidered (i.e. it should be used as a quality control tool).

The second antenatal visit1-35 What are the aims of the second antenatal visit?If the results of the screening tests were not available by the end of the firstantenatal visit, a second visit should be arranged 2 weeks later to review andact on these results. It would then be important to perform the second screenfor risk factors. If possible, all the results of the screening tests should beobtained at the first visit.

THE SECOND ANTENATAL VISIT 27

Assessing the results of the specialscreening investigations1-36 How should you interpret the results of the VDRL or RPRscreening tests for syphilis?The correct interpretation of the results is of the greatest importance:

1. If either the VDRL (Venereal Disease Research Laboratory), or RPR (RapidPlasmin Reagin) test is negative, then the patient does not have syphilis andno further tests for syphilis are needed.

2. If the VDRL or RPR titre is 1:16 or higher, the patient has syphilis and mustbe treated.

3. If the VDRL or RPR titre is 1:8 or lower (or the titre is not known), thelaboratory should test the same blood sample by means of the TPHA(Treponema Pallidum Haemagglutin Assay) or FTA (Fluorescent TreponemalAntibody) test:

◦ If the TPHA or FTA is also positive, the patient has syphilis and must be fullytreated.

◦ If the TPHA or FTA is negative, then the patient does not have syphilis and,therefore, need not be treated.

◦ If a TPHA or FTA test cannot be done, and the patient has not been fullytreated for syphilis in the past 3 months, she must be given a full course oftreatment. A syphilis rapid test can be done instead of a TPHA or FTA test.

A VDRL or RPR titre of less than 1 in 16 may be caused bysyphilis.

NOTEThe VDRL, RPR or rapid syphilis test may still be negative during the first fewweeks after infection with syphilis as the patient has not yet had enough time toform antibodies. The VDRL and RPR tests detect regain antibodies which indicatepresent syphilis infection while the TPHA, FTA and syphilis rapid tests detectspirichaetal antibodies which indicate syphilis at ant time in that person’s life.

28 ANTENATAL CARE

1-37 How should the results of the on-site RPR card test andsyphilis rapid test be interpreted?If either test is negative the patient does not have syphilis.

1. If the RPR card test is strongly positive the patient most likely has syphilisand treatment should be started. However, a blood specimen must be sent tothe laboratory to confirm the diagnosis, and the patient must be seen again 1week later. Further treatment will depend on the result of the laboratory test.It is important to explain to the patient that the result of the card test needsto be checked with a laboratory test. If the test is weakly positive a bloodspecimen must still be sent to the laboratory and the patient seen 1 weeklater. Any treatment will depend on the result of the laboratory test.

2. If the syphilis rapid test is positive the person either has active (untreated)syphilis or was infected in the past and no longer has active disease. Thediagnosis of active syphilis must be confirmed or rejected by a VDRL or RPRtest. It is advisable that treatment for syphilis be started immediately whilewaiting for the result of the RPR or VDRL test. A TPHA can be used as ascreening test in the same way as the syphilis rapid test.

1-38 What is the treatment of syphilis in pregnancy?The treatment of choice is penicillin. If the patient is not allergic to penicillin,she is given benzathine penicillin (Bicillin LA or Penilente LA) 2.4 millionunits intramuscularly weekly for 3 weeks. At each visit 1.2 million units isgiven into each buttock. This is a painful injection so the importance ofcompleting the full course must be impressed on the patient.

Benzathine penicillin crosses the placenta and also treats the fetus.

If the patient is allergic to penicillin, she is given erythromycin 500 mg 6hourly orally for 14 days. This may not treat the fetus adequately, however.Tetracycline is contraindicated in pregnancy as it may damage the fetus.

The patient’s sexual partner must also be treated.

ASSESSING THE RESULTS OF THE SPECIAL SCREENING INVESTIGATIONS 29

1-39 How should the results of the rapid HIV test be interpreted?1. If the rapid HIV test is NEGATIVE, there is a very small chance that the

patient is HIV positive. The patient should be informed about the result andgiven counselling to help her to maintain her negative status.

2. If the rapid HIV test is POSITIVE, a second rapid test should be done with akit from another manufacturer. If the second test is also positive, then thepatient is HIV positive. The patient should be given the result and post-testcounselling for an HIV-positive patient should be provided.

3. If the first rapid test is positive and the second negative, the patient’s HIVstatus is uncertain. This information should be given to the patient and bloodshould be taken and sent to the nearest laboratory for an ELISA test for HIV:

◦ If the ELISA test is negative, there is only a very small chance that the patientis HIV positive.

◦ If the ELISA test is positive, the patient is HIV positive.

1-40 What should you do if the cervical cytology result is abnormal?1. A patient whose smear shows an infiltrating cervical carcinoma must

immediately be referred to the nearest gynaecological oncology clinic (level 3hospital). The duration of pregnancy is very important, and this information(determined as accurately as possible) must be available when the unit isphoned.

2. A patient with a smear showing a low grade CIL (cervical intra-epitheliallesion) such as CIN I (cervical intra-epithelial neoplasia), atypia or onlycondylomatous changes is checked after 9 months, or as recommended on thecytology report.

3. A patient with a smear showing a high grade CIL, such as CIN II or III oratypical condylomatous changes, must get an appointment at the nearestgynaecology or cytology clinic.

4. Abnormal vaginal flora is only treated if the patient is symptomatic.

It is essential to record on the antenatal card the plan that hasbeen decided upon, and to ensure that the patient is fullytreated after delivery.

30 ANTENATAL CARE

1-41 What should you do if the patient’s blood group is Rhnegative?Between 5 and 15% of patients are Rhesus negative (i.e. they do not have theRhesus D antigen on their red cells). The blood grouping laboratory will lookfor Rhesus anti-D antibodies in these patients. If the Rh card test was used,blood must be sent to the blood grouping laboratory to confirm the result andlook for Rhesus anti-D antibodies.

1. If there are no anti-D antibodies present, the patient is not sensitised. Bloodmust be taken at 26, 32 and 38 weeks of pregnancy to determine if the patienthas developed anti-D antibodies since the first test was done.

2. If anti-D antibodies are present, the patient has been sensitised to the RhesusD antigen. With an anti-D antibody titre of 1:16 or higher, she must bereferred to a centre which specialises in the management of this problem. Ifthe titre is less than 1:16, the titre should be repeated within 2 weeks or asdirected by the laboratory.

1-42 What should you do if the ultrasound findings do not agreewith the patient’s dates?Between 18 and 22 weeks:

1. If the duration of pregnancy, as suggested by the patient’s menstrual dates,falls within the range of the duration of pregnancy as given by theultrasonographer (usually 3–4 weeks), the dates should be accepted ascorrect.

2. However, if the dates fall outside the range of the ultrasound assessment,then the dates must be regarded as incorrect.

3. If the ultrasound examination is done in the first trimester (14 weeks or less),the error in determining the gestational age is only one week.

Remember, if the patient is more than 24 weeks pregnant, ultrasonologycannot be used to accurately determine the gestational age.

1-43 What action should you take if an ultrasound examination at18 to 22 weeks shows a placenta praevia?In most cases the placenta will move out of the lower segment as pregnancyprogresses, as the size of the uterus increases more than the size of theplacenta. Therefore, a follow-up ultrasound examination must be arranged at

ASSESSING THE RESULTS OF THE SPECIAL SCREENING INVESTIGATIONS 31

32 weeks, where a placenta praevia type II or higher has been diagnosed, toassess whether the placenta is still praevia.

1-44 What should you do if the ultrasound examination shows apossible fetal abnormality?The patient must be referred to a level 3 hospital for detailed ultrasoundevaluation and a decision about further management.

Grading the riskOnce the results of the special investigations have been obtained, all patientsmust be graded into a risk category. (A list of risk factors and the level of careneeded is given in Appendix 1). A few high-risk patients would have alreadybeen identified at the first antenatal visit while others will be identified at thesecond visit.

1-45 What are the risk categories?There are 3 risk categories:

1. Low (average) risk.2. Intermediate risk.3. High risk.

A low-risk patient has no maternal or fetal risk factors present. Thesepatients can receive primary care from a midwife.

An intermediate-risk patient has a problem which requires some, but notcontinuous, additional care. For example, a grande multipara should beassessed at her first or second visit for medical disorders, and at 34 weeks foran abnormal lie. She also requires additional care during labour andpostpartum. She, therefore, is at an increased risk of problems only duringpart of her pregnancy, labour and puerperium. Most of the antenatal care inthese patients can be given by a midwife.

A high-risk patient has a problem which requires continuous additional care.For example, a patient with heart valve disease or a patient with a multiplepregnancy. These patients usually require care by a doctor.

32 ANTENATAL CARE

Subsequent visitsGeneral principles:

1. The subsequent visits must be problem oriented.2. The visits at 28, 34 and 41 weeks are more important visits. At these visits,

complications specifically associated with the duration of pregnancy arelooked for.

3. From 28 weeks onwards the fetus is viable and the fetal condition must,therefore, be regularly assessed.

1-46 When should a patient return for further antenatal visits?If a patient books in the first trimester, and is found to be at low risk, hersubsequent visits can be arranged as follows:

1. Every 8 weeks until 28 weeks.2. The next visit is 6 weeks later at 34 weeks.3. Primigravids are then seen at 36 weeks and multigravidas at 38 weeks.

However, multigravidas are also seen again at 36 weeks if a breechpresentation was present at 34 weeks.

4. Thereafter primigravidas are seen at 40 and 41 weeks while multigravidas areseen at 41 weeks if they have not yet delivered.

5. In some rural areas it may be necessary to see low-risk patients less oftenbecause of the large distances involved. The risk of complications with lessfrequent visits in these patients is minimal. Visits may be scheduled asfollows: after the first visit (combining the booking and second visit), thefollow-up visits at 28, 34 and 41 weeks.

1-47 Which patients should have more frequent antenatal visits?If a complication develops, the risk grading will change. This change must beclearly recorded on the patient’s antenatal card. Subsequent visits will now bemore frequent, depending on the nature of the risk factor.

Primigravidas, whenever possible, must be seen every 2 weeks from 36weeks, even if it is only to check the blood pressure and test the urine forprotein, because they are a high-risk group for developing pre-eclampsia.

SUBSEQUENT VISITS 33

A waiting area (obstetric village), where cheap accommodation is availablefor patients, provides an ideal solution for some intermediate-risk patients,high-risk patients and the above-mentioned primigravidas, so that they canbe seen more regularly.

The visit at 28 weeks1-48 What important complications of pregnancy should be lookedfor?

1. Antepartum haemorrhage becomes a very important high-risk factor from 28weeks.

2. Early signs of pre-eclampsia may now be present for the first time, as it is aproblem which develops in the second half of pregnancy. Therefore, thepatient must be assessed for proteinuria and a rise in the blood pressure.

3. Cervical changes in a patient who is at high risk for preterm labour, e.g.multiple pregnancy, a history of previous preterm labour, or polyhydramnios.

4. If the symphysis-fundal height measurement is below the 10th centile, assessthe patient for causes of poor fundal growth.

5. If the symphysis-fundal height measurement is above the 90th centile, assessthe patient for the causes of a uterus larger than dates.

6. Anaemia may be detected for the first time during pregnancy.7. Diabetes in pregnancy may present now with glycosuria. If so, a random

blood glucose concentration must be measured.

1-49 Why is an antepartum haemorrhage a serious sign?1. Abruptio placentae causes many perinatal deaths.2. It may also be a warning sign of placenta praevia.

34 ANTENATAL CARE

1-50 How should you monitor the fetal condition?1. All women should be asked about the frequency of fetal movements and

warned that they must report immediately if the movements suddenlydecrease or stop.

2. If a patient has possible intra-uterine growth restriction or a history of aprevious fetal death, then she should count fetal movements once a day from28 weeks and record them on a fetal movement chart.

The visit at 34 weeks1-51 Why is the 34 weeks visit important?

1. All the risk factors of importance at 28 weeks (except for preterm labour) arestill important and must be excluded.

2. The lie of the fetus is now very important and must be determined. If thepresenting part is not cephalic, then an external cephalic version must beattempted at 36 weeks if there are no contraindications. A grande multiparawho goes into labour with an abnormal lie is at high risk of rupturing heruterus.

3. Patients who have had a previous caesarean section must be assessed with aview to the safest method of delivery. A patient with a small pelvis, aprevious classical caesarean section, as well as other recurrent causes for acaesarean section must be booked for an elective caesarean section at 39weeks.

4. The patient’s breasts must be examined again for flat or inverted nipples, oreczema of the areolae which may impair breastfeeding. Eczema should betreated.

5. If the first HIV screen was negative, it should be repeated around 32 weeksgestation to detect any late infections.

THE VISIT AT 34 WEEKS 35

The visit at 41 weeks1-52 Why is the visit at 41 weeks important?A patient, whose pregnancy extends beyond 42 weeks, has an increased riskof developing the following complications:

1. Intrapartum fetal distress.2. Meconium aspiration.3. Intra-uterine death.

1-53 How should you manage a patient who is 41 weeks pregnant?1. A patient with a complication such as intra-uterine growth restriction

(retardation) or pre-eclampsia must have labour induced.2. A patient who booked early and was sure of her last menstrual period and

where, at the booking visit, the size of the uterus corresponded to theduration of pregnancy by dates must have the labour induced on the day shereaches 42 weeks. The same applies to a patient whose duration of pregnancywas confirmed by ultrasound examination before 24 weeks.

3. A patient who is unsure of her dates, or who booked late, must have anultrasound examination on the day she reaches 42 weeks to determine theamount of amniotic fluid present:

◦ If the amniotic fluid index is 5 or more (or the largest pool of liquor measures3 cm or more) and the patient reports good fetal movement, she should bereassessed in one weeks time.

◦ If the amniotic fluid largest pool of liquor measures less than 3 cm, thepregnancy must be induced.

NOTEThe amniotic fluid index measures the largest vertical pool of liquor in the each ofthe 4 quadrants of the uterus and adds them together.

It is very important that the above problems are actively looked for at 28, 34and 41 weeks. It is best to memorise these problems and check then one byone at each visit.

36 ANTENATAL CARE

Remember that the commonest cause of being postterm iswrong dates.

1-54 How should the history, clinical findings and results of thespecial investigations be recorded in low-risk patients?There are many advantages to a hand-held antenatal card which records allthe patient’s antenatal information. It is simple, cheap and effective. It isuncommon for patients to lose their records. The clinical record is thenalways available wherever the patient presents for care. The clinic need onlyrecord the patient’s personal details such as name, address and age togetherwith the dates of her clinic visits and the result of any special investigations.

On the one side of the card are recorded the patient’s personal details,history, estimated gestational age, examination findings, results of the specialinvestigations, plan of management and proposed future family planning. Onthe other side are recorded all the maternal and fetal observations madeduring pregnancy.

It is important that all antenatal women have a hand-heldantenatal card.

1-55 What topics should you discuss with patients during the healtheducation sessions?The following topics must be discussed:

1. Danger symptoms and signs.2. Dangerous habits, e.g. smoking or drinking alcohol.3. Healthy eating.4. Family planning.5. Breastfeeding.6. Care of the newborn infant.7. The onset of labour and labour itself must also be included when the patient

is a primigravida.8. Avoiding HIV infection or counselling if HIV positive.

THE VISIT AT 41 WEEKS 37

1-56 What symptoms or signs, which may indicate the presence ofserious complications, must be discussed with patients?

1. Symptoms and signs that suggest abruption placenta:◦ Vaginal bleeding.◦ Persistent, severe abdominal pain.◦ Decreased fetal movements.

2. Symptoms and signs that suggest pre-eclampsia:◦ Persistent headache.◦ Flashes before the eyes.◦ Sudden swelling of the hands, feet or face.

3. Symptoms and signs that suggest preterm labour:◦ Rupture of the membranes.◦ Regular uterine contractions before the expected date of delivery.

Managing women with HIV infection1-57 What is HIV infection and AIDS?AIDS (Acquired Immune Deficiency Syndrome) is a severe chronic illnesscaused by the human immunodeficiency virus (HIV). Women with HIVinfection can remain clinically well for many years before developing signs ofthe disease. Severe HIV disease is called AIDS. These patients have a damagedimmune system and often die of other opportunistic infections such astuberculosis.

1-58 Is AIDS an important cause of maternal death?As the HIV epidemic spreads, the number of pregnant women dying of AIDShas increased dramatically. In some countries, such as South Africa, AIDS isnow the commonest cause of maternal death. Therefore all pregnant womenmust be screened for HIV infection.

All pregnant women must be screened for HIV infection as AIDSis the commonest cause of maternal death in South Africa.

38 ANTENATAL CARE

1-59 Does pregnancy increase the risk of progression fromasymptomatic HIV infection to AIDS?Pregnancy appears to have little or no effect on the progression fromasymptomatic to symptomatic HIV infection. However, in women whoalready have symptomatic HIV infection, pregnancy may lead to a more rapidprogression to AIDS.

1-60 How is the severity of HIV infection classified?The severity and progression of HIV infection during pregnancy can bemonitored by:

1. Assessing the clinical stage of the disease◦ Stage 1: Clinically well.◦ Stage 2: Mild clinical problems.◦ Stage 3: Moderate clinical problems.◦ Stage 4: Severe clinical problems (i.e. AIDS).

2. Measuring the CD4 count in the bloodA falling CD4 count is an important marker of progression in HIV infection.It is an indicator of the degree of damage to the immune system. The normaladult CD4 count is 700 to 1100 cells/mm3. A CD4 count equal or below 350cells/mm3 indicates severe damage to the immune system.

The CD4 count is an important marker of the severity andprogression of HIV infection during pregnancy.

1-61 What clinical signs suggest stage 1 and 2 HIV infection?Persistent generalised lymphadenopathy is the only clinical sign of stage 1HIV infection.

Signs of stage 2 HIV infection include:

• Repeated or chronic mouth or genital ulcers.• Extensive skin rashes.• Repeated upper respiratory tract infections such as otitis media or sinusitis.• Herpes zoster (shingles).

MANAGING WOMEN WITH HIV INFECTION 39

1-62 What are important features suggesting stage 3 or 4 HIVinfection?Features of stage 3 HIV infection include:

• Unexplained weight loss.• Oral candidiasis (thrush).• Cough, fever and night sweats suggesting pulmonary tuberculosis.• Cough, fever and shortness of breath suggesting bacterial pneumonia.• Chronic diarrhoea or unexplained fever for more than 1 month.• Pulmonary tuberculosis.

Features of stage 4 HIV infection include:

• Severe weight loss.• Severe or repeated bacterial infections, especially pneumonia.• Severe HIV-associated infections such as oesophageal candidiasis (which

presents with difficulty swallowing) and Pneumocystis pneumonia (whichpresents with cough, fever and shortness of breath).

• Malignancies such as Kaposi’s sarcoma.• Extrapulmonary tuberculosis (TB).

1-63 How should pregnant women with a positive HIV screeningtest be managed?It is very important to identify women with HIV infection as soon as possiblein pregnancy so that they can be carefully assessed and their managementcan be planned. The HIV management should be integrated into the rest ofthe antenatal care. All women with a positive HIV screening test must havetheir CD4 count determined as soon as the HIV screening result is obtained.

Pregnant women with HIV infection need either antiretroviral prophylaxis ortreatment.

Determine and note the clinical stage of the disease on the antenatal record.

All HIV-positive women must have a CD4 count.

40 ANTENATAL CARE

1-64 What are the indications for antiretroviral prophylaxis inpregnancy?All pregnant women who are HIV positive but appear clinically well with aCD4 count above 350 need antiretroviral (ARV) prophylaxis only.

All pregnant women who are HIV positive should receive eitherantiretroviral prophylaxis or treatment.

1-65 What is antiretroviral prophylaxis?Antiretroviral prophylaxis aims at reducing the risk of the mother infectingher fetus and newborn infant with HIV (prevention of mother-to-childtransmission or PMTCT). It is not aimed at treating the mother’s HIVinfection and therefore is given to HIV positive women who are clinicallywell with a CD4 count above 350 cells/mm3. With prophylaxis the womenstop their ARVs once they have stopped breastfeeding and there is no furtherrisk of mother-to-child transmission (WHO option B). ARV prophylaxisshould be started at 14 weeks or as soon as possible thereafter. It will reducethe risk of HIV transmission from mother to infant to 2%, compared to 30%without prophylaxis.

For prophylaxis a fixed dose combination (FDC) pill is taken daily, usually atbedtime.

NOTEWHO option A, which is no longer used in South Africa, consists of Zidovudine(AZT) 300 mg orally twice daily started at 14 weeks gestation. A single dose ofnevirapine 200mg is given to the mother at the onset of labour and AZT 300mg 3hourly is given during labour. In addition, a single dose of Truvada, a combinationof tenofovir (TDF) and emtricitabine (FTC), must be given to the mother during orimmediately after labour to prevent nevirapine resistance in the mother. Dailynevirapine is started in the infant. This regime is known as dual therapy and willreduce the risk of HIV transmission from mother to infant to 2%, compared to 30%without prophylaxis. Truvada is the trade name of the combination of TDF andFTC. It is given to prevent nevirapine resistance in the mother.

Antiretroviral prophylaxis can reduce the risk of perinatal HIVtransmission to 2%.

MANAGING WOMEN WITH HIV INFECTION 41

1-66 What are the indications for antiretroviral treatment inpregnancy?The indications for ARV antiretroviral treatment (ART) instead of ARVprophylaxis are any of the following:

• Clinical signs of stage 3 or 4 HIV infection.• A CD4 count equal or below 350 cells/mm3• Tuberculosis.

Therefore, women with clinical signs of stage 3 or 4 HIV disease needantiretroviral treatment even if their CD4 count has not yet dropped to below350. The difference between ARV prophylaxis and treatment is that womenon treatment continue their ARVs for life and do not stop once breastfeedingis completed. In future all pregnant women who are HIV positive willprobably be given treatment with ARVs for life (WHO option B+).

1-67 What is antiretroviral treatment?The aim of antiretroviral treatment is to lower the viral load and allow theimmune system to recover. This will both reduce the risk of HIV transmissionto the infant and treat the mother’s HIV infection. ARV treatment consists oftaking TDF, FTC and EFV as a FDC tablet daily. Patients on antiretroviraltreatment are not also given antiretroviral prophylaxis as antiretroviraltreatment alone provides excellent prophylaxis. The use of FDC duringpregnancy is the same for both prophylaxis and treatment.

Women who are already on ARV treatment when they book for antenatalcare should continue on their ARV treatment during the pregnancy. If notalready on FDC, their ARV’s may be changed to FDC by a special HIV clinic.

A fixed dose combination of antiretroviral drugs is used for HIVprophylaxis and treatment during pregnancy.

1-68 Can an HIV-positive woman be cared for in a primary-careclinic?Most women who are HIV positive are clinically well with a normalpregnancy. Others may only have minor problems (stage 1 or 2). Thesewomen can usually be cared for in a primary-care clinic throughout their

42 ANTENATAL CARE

pregnancy, labour, and puerperium, provided they remain well and theirpregnancy is normal. Women with a pregnancy complication should bereferred to hospital as would be done with HIV-negative patients. Womenwith severe (stage 3 or 4) HIV-related problems or severe treatment sideeffects will need to be referred to a special HIV clinic or hospital.

Most HIV-positive women can be managed at a primary-careclinic during pregnancy.

1-69 How are pregnant women with HIV infection managed at aprimary-care clinic?The management of pregnant women with HIV infection is very similar tothat of non-pregnant adults with HIV infection. The most important step is toidentify those pregnant women who are HIV positive.

The principles of management of pregnant women with HIV infection at aprimary-care clinic are:

• Make the diagnosis of HIV infection by offering HIV screening to allpregnant women at the start of their antenatal care.

• Assess the CD4 count in all HIV-positive women as soon as their positiveHIV status is known.

• Screen for clinical signs of HIV infection and clinical staging at eachantenatal visit.

• Screen for symptoms of TB.• Good diet. Nutritional support may be needed.• Emotional support and counselling.• Prevention of mother-to-child transmission (PMTCT) of HIV.• Start ARV (antiretroviral) prophylaxis or treatment when indicated.• Early referral if there are pregnancy or HIV complications.

1-70 What preparation is needed for antiretroviral treatment?Preparing a patient to start ARV treatment is very important. This requireseducation, counselling and social assessment before ARV treatment can bestarted. These patients must have regular clinic attendance and must learnabout their illness and the importance of excellent adherence (taking theirARV drugs at the correct time every day). They also need to know the side

MANAGING WOMEN WITH HIV INFECTION 43

effects of ARV drugs and how to recognise them. Careful generalexamination and some blood tests are also needed before starting ARVtreatment. ARV management should start as soon as possible, preferablywithin a few days. It usually takes 2 weeks to prepare a patient for treatment.

1-71 How should pregnant women on antiretroviral treatment bemanaged?The national drug protocol using a FDC tablet should be followed. It is veryimportant that staff at the antenatal clinic are trained to manage women withHIV infection. They should work together with the local antiretroviral (ARV)clinic or HIV service of the local hospital.

1-72 What drugs are used in the fixed dose combination pill forstarting antiretroviral treatment during pregnancy?A fixed dose combination regimen of three drugs is usually used as first linetreatment in South Africa. The FDC consists of tenofovir (TDF) 300 mg,emtricitabine (FTC) 200 mg and efavirenz (EFV) 600 mg.

This is the current national first-line standard drug combination used duringpregnancy. Zidovudine (AZT) may replace TDF while emtricitabine (FTC)may replace 3TC if necessary.

1-73 What are the side effects of antiretroviral drugs?Pregnant women on antiretroviral prophylaxis or treatment may experienceside effects to the ARV drugs. These are usually mild and occur during thefirst six weeks of treatment. However, side effects may occur at any time thatpatients are taking antiretroviral treatment. It is important that the staff atprimary-care clinics are aware of these side effects and that they ask forsymptoms and look for signs at each clinic visit. Side effects withantiretroviral treatment are more common than with antiretroviralprophylaxis during pregnancy.

Common early side effects during the first few weeks of starting ARVantiretroviral drugs treatment include:

• Lethargy, tiredness and headaches• Nausea, vomiting and diarrhoea• Muscle pains and weakness

44 ANTENATAL CARE

These mild side effects usually disappear on their own. They can be treatedsymptomatically. It is important that antiretroviral treatment is continuedeven if there are mild side effects.

EFV may cause insomnia (cannot sleep), abnormal dreams and rarelypsychiatric symptoms.

More severe side effects, which can be fatal, include:

• TDF may cause decreased renal function.• NVP may cause severe skin rashes. All patients with severe skin rashes must

be referred urgently to the HIV clinic.• AZT may suppress the bone marrow, causing anaemia. There may also be a

reduction in the white cell and platelet counts.• Hepatitis can be caused by all antiretroviral drugs, but especially by NVP.• Lactic acidosis is a late but serious side effect, especially with stavudine (d4T).

It presents with weight loss, tiredness, nausea, vomiting, abdominal pain andshortness of breath in patients who have been well on antiretroviraltreatment for a few months.

Staff at primary-care clinics must be aware and look out for these veryimportant side effects.

1-74 Is HIV/TB co-infection common in pregnancy?Tuberculosis (TB) is common in patients with HIV who have a weakenedimmune system. Therefore co-infection with both HIV and TB bacilli iscommon during pregnancy in communities with a high prevalence of HIVand TB.

Symptomatic screening for TB must be done at each visit by weighing thepatient, to check for weight loss, and by asking her about a chronic cough,fever or profuse night sweats. If any one of these are present furtherinvestigations for TB are required.

TB is treated with four drugs (rifampicin, isoniazid, pyrizinamide andethambutol) which may interact and increase the adverse effects ofantiretroviral ARV drugs. Treatment of both HIV and tuberculosis should beintegrated with routine antenatal care whenever possible.

MANAGING WOMEN WITH HIV INFECTION 45

Case study 1A 36 year old gravida 4 para 3 patient presents at her first antenatal clinicvisit. She does not know the date of her last menstrual period. The patientsays that she had hypertension in her last 2 pregnancies. The symphysis-fundus height measurement suggests a 32 week pregnancy. At her secondvisit, the report of the routine cervical smear states that she has a low gradecervical intra-epithelial lesion.

1. Why is her past obstetric history important?Because hypertension in a previous pregnancy places her at high risk ofhypertension again in this pregnancy. She must be carefully examined forhypertension and proteinuria at this visit and at each subsequent visit. Thiscase stresses the importance of a careful history at the booking visit.

2. How accurate is the symphysis-fundus height measurement indetermining that the pregnancy is of 32 weeks duration?This is the most accurate clinical method to determine the size of the uterusfrom 18 weeks gestation. If the uterine growth, as determined by symphysis-fundus measurement, follows the curve on the antenatal card, the gestationalage as determined at the first visit is confirmed.

3. Why would an ultrasound examination not be helpful indetermining the gestational age?Ultrasonology is accurate in determining the gestational age only up to 24weeks. Thereafter, the range of error is virtually the same as that of a clinicalexamination.

4. What should you do about the result of the cervical smear?The cervical smear must be repeated after 9 months. It is important to writethe result in the antenatal record and to indicate what plan of managementhas been decided upon.

46 ANTENATAL CARE

Case study 2At booking a patient has a positive VDRL test with a titre of 1:4. She has hadno illnesses or medical treatment during the past year. By dates andabdominal palpation she is 26 weeks pregnant.

1. What does the result of this patient’s VDRL test indicate?The positive VDRL test indicates that the patient may have syphilis. However,the titre is below 1:16 and, therefore, a definite diagnosis of syphilis cannot bemade without a further blood test.

2. What further test is needed to confirm or exclude a diagnosis ofsyphilis?If possible, the patient must have a TPHA or FTA or rapid syphilis test. Apositive result of any of these tests will confirm the diagnosis of syphilis. Ifthese tests are not available, the patient must be treated for syphilis.

3. Why is the fetus at risk of congenital syphilis?Because the spirochaetes that cause syphilis may cross the placenta andinfect the fetus.

4. What treatment is required if the patient has syphilis?The patient should be given 2,4 million units of benzathine penicillin (BicillinLA or Penilente LA) intramuscularly weekly for 3 weeks. Half of the dose isgiven into each buttock. Benzathine penicillin will cross the placenta and alsotreat the fetus.

5. What other medical conditions is this patient likely to sufferfrom?She may have other sexually transmitted diseases such as HIV.

CASE STUDY 2 47

Case study 3A healthy primigravid patient of 18 years booked for antenatal care at 22weeks pregnant. Her rapid syphilis and HIV tests were negative. Her Rhblood group is positive according the Rh card test. She is classified as at lowrisk for problems during her pregnancy.

1. What is the best time for a pregnant woman to attend anantenatal care clinic for the first time?If possible, all pregnant women should book for antenatal care within thefirst 12 weeks. The duration of pregnancy can then be confirmed withreasonable accuracy on physical examination, medical problems can bediagnosed early, and screening tests can be done as soon as possible.

2. When should this patient return for her next antenatal visit?She should attend at 28 weeks.

3. What important complications should be looked for in thispatient at her 28 week visit?Anaemia, early signs of pre-eclampsia, a uterus smaller than expected(suggesting intra-uterine growth restriction), or a uterus larger than expected(suggesting multiple pregnancy). A history of antepartum haemorrhageshould also be asked for.

4. When should she attend antenatal clinic in the last trimester ifshe and her fetus remain normal?The next visit should be at 34 weeks, and then every 2 weeks until 41 weeks.

Case study 4A 24 year old gravida 2 para 1 attends the booking antenatal clinic and is seenby a midwife. The previous obstetric history reveals that she had a caesareansection at term because of poor progress in labour. She is sure of her last

48 ANTENATAL CARE

menstrual period and is 14 weeks pregnant by dates. On abdominal palpationthe height of the uterine fundus is halfway between the symphysis pubis andthe umbilicus.

1. What further important information must be obtained about theprevious caesarean section?The exact indication for the caesarean section must be found in the patient’shospital notes. In addition, the type of uterine incision made must beestablished, i.e. whether it was a transverse lower segment or a verticalincision.

2. Why is it important to obtain this additional information?If the patient had a caesarean section for a non-recurring cause and she had atransverse lower segment incision, she may be allowed a trial of labour.

3. In which risk category would you place this patient?She should be placed in the intermediate category.

4. How must you plan this patient’s antenatal care?Her next visit must be arranged at a hospital. If possible, the hospital whereshe had the caesarean section so that the required information may beobtained from her folder. Then she may continue to receive her antenatal carefrom the midwife at the clinic until 36 weeks gestation. From then on thepatient must again attend the hospital antenatal clinic where the decisionabout the method of delivery will be made.

5. Which of the two estimations of the duration of pregnancy is thecorrect one?A fundal height measurement midway between the symphysis pubis and theumbilicus suggests a gestational age of 16 weeks. According to her dates, thepatient is 14 weeks pregnant. As the difference between these twoestimations is less than 3 weeks, the duration of pregnancy as calculated fromthe patient’s dates must be accepted as the correct one.

CASE STUDY 4 49

Figure 1-1: The front of an antenatal record card

50 ANTENATAL CARE

Figure 1-2: The back of an antenatal record card

CASE STUDY 4 51

Figure 1-3: Clinic checklist

52 ANTENATAL CARE

Figure 1-4: Back page of clinic checklist

CASE STUDY 4 53

1ASkills workshop 1A:General examination atthe first antenatal visit

ObjectivesWhen you have completed this skills workshop you should be able to:

• Take an adequate history.• Perform a good general examination.• Test the patient’s urine.• Perform and interpret a pregnancy test.

History takingThe purpose of taking a history is to assess the past and present obstetrical,medical and surgical problems in order to detect risk factors for the patientand her fetus.

A The last normal menstrual period (LMP)1. Does she have a normal and regular menstrual cycle?2. When did she last have a normal menstrual period?

It may be difficult to establish the LMP when she has an irregular cycle.

If the patient is uncertain of her dates, it is often helpful to relate the onset ofpregnancy to some special event, e.g. Christmas or school holidays. Forexample “How many periods have you had since your birthday?, or “Howmany periods had you missed before New Year?

54 SKILLS WORKSHOP 1A: GENERAL EXAMINATION AT THE FIRST ANTENATAL VISIT

The expected date of delivery (EDD) must now be estimated as accurately aspossible. A quick estimate can be made by taking the date of the LMP andadding 9 months and 1 week. Therefore, if the LMP was on 2-2-09, the EDDwill be on 9-11-09. If the LMP is 27-10-08, the EDD will be 3-8-09.

B Past obstetric historyIt is important to know how many pregnancies the patient has lost. Patientsoften forget about miscarriages and ectopic pregnancies, and may also notmention previous pregnancies from another husband or boyfriend. Questionswhich need to be asked are therefore:

How many times have you been pregnant? Ask specifically aboutmiscarriages and ectopic pregnancies.

How many children do you have? This can bring to light the fact that shehas had twins.

How many children do you have who are alive? If a child has died, oneneeds to know approximately at what age the child died, and the cause ofdeath, e.g. “died at 15 months from diarrhoea”. If the death occurred beforedelivery or during the neonatal period (first 28 days), information about thecause of death is of particular importance. Approximate birth weights ofprevious children, and the approximate period of gestation, if the infant wassmall or preterm, are useful. Low birth weight suggests either growthrestriction or preterm delivery, and heavy infants should alert one to thepossibility of maternal diabetes.

Were you well during your previous pregnancies? In addition, askingabout any episodes of hospitalisation can be helpful.

How long were you in labour? It is important to know if she has had along labour, as this may indicate cephalopelvic disproportion.

The type of delivery is important. Any form of assisted delivery, including acaesarean section, suggests that there may have been cephalopelvicdisproportion. The patient should always be asked if she knows the reason forhaving had a caesarean section. Information about the type of incision madein the uterus must be obtained from the hospital where the patient had hercaesarean section. A history of impacted shoulders is important as it suggeststhat the infant was very large.

HISTORY TAKING 55

A retained placenta or postpartum haemorrhage in previous pregnanciesshould be asked for specifically.

All these findings should be recorded briefly on the antenatal clinic record.

Figure 1A-1: Recording past obstetric history

C Medical historyPatients must be specifically asked about diabetes, epilepsy, hypertension,renal disease, heart valve disease and tuberculosis. Also ask about any otherillnesses which she may have had. Asking about allergies and medicationoften brings to light a problem which the patient may have forgotten, orthought not to be of significance. Always ask whether she has ever had anoperation or has been admitted to hospital and, if so, where and why.

Any abnormal findings in the medical history should be recorded, with a briefcomment, on the antenatal record.

D Family planningThe patient’s family planning needs and wishes should be discussed at thefirst antenatal visit. She (and her consort) should be encouraged to plan thenumber and spacing of their children. The contraceptive methods used shouldalso be in keeping with these plans. The patient’s wishes should be respected.The outcome of these discussions should be recorded on the antenatal record.

56 SKILLS WORKSHOP 1A: GENERAL EXAMINATION AT THE FIRST ANTENATAL VISIT

Examination of the patientE General examinationThe following should be assessed:

1. Height – measured in cm. This does not require special equipment. A tapemeasure stuck to the wall, or a wall marked at 1 cm intervals is adequate. Thepatient should not wear shoes when her height is measured.

2. Weight – measured in kilograms. The patient should only wear light clothingwhile her weight (mass) is being measured. The scale should be periodicallychecked for accuracy, and if necessary re-calibrated. Latest research indicatesthat poor weight gain, no weight gain or excessive weight gain duringpregnancy is not important. Worldwide there is a swing away from weighingpatients except at the first antenatal visit.

3. General appearance:◦ Is the patient thin or overweight?◦ Is there evidence of recent weight loss?◦ The presence of pallor, oedema, jaundice and enlarged lymph nodes should be

specifically looked for.

F Examination of the thyroid glandThis can be difficult when the patient has a short, thick neck, or when she isobese. Look for an obviously enlarged thyroid gland (a goitre). The patientshould be referred for further investigation when there is obviousenlargement of the thyroid, the thyroid feels nodular or a single nodule canbe felt. A normal thyroid gland is usually slightly enlarged during pregnancy.

G Examination of the breastsThe patient must be undressed in order for the breasts to be examinedproperly. The breasts should be examined with the patient both sitting andlying on her back, with her hands above her head.

Look: There may be obvious gross abnormalities. Particularly look for anydistortion of the breasts or nipples. The nipples should be specificallyexamined with regard to their position and deformity (if any), discharge, andwhether or not they are inverted. Note any eczema of the areola.

EXAMINATION OF THE PATIENT 57

Feel: Feel for lumps, using the flat hand rather than the fingers.

H Examination of the lymph nodesWhen the thyroid is examined, the neck should also be thoroughly examinedfor enlarged lymph nodes. The areas above the clavicles and behind the earsmust be palpated. The axillae and inguinal areas should also be examined forenlarged lymph nodes.

Patients with AIDS usually have enlarged lymph nodes in all these areas.

I Examination of the chestThe patient must be undressed. Look for any of the following signs:

1. Any deformities or scars.2. Any abnormality of the spine.3. Any difficulty breathing (dyspnoea).

J Examination of the cardiovascular system1. Pulse: The rate is important. A rapid heart rate is almost always an indication

that the patient is anxious or ill.2. Blood pressure.

Testing the patient’s urineUrine is most conveniently tested using reagent strips. Some strips willmeasure pH, glucose, ketones, protein and blood (e.g. Lenstrip-5) while otherswill also measure bilirubin, specific gravity, urobilinogen, nitrite andleucocytes (e.g. Multistix and Combi-9 Test). However, measuring glucose andprotein are most important and, therefore, only glucose and protein (e.g.Uristix) need to be measured in routine antenatal screening. This is thecheapest method. The cost can be reduced further by cutting the strips in two,longitudinally.

The strips should be kept in their containers, away from direct sunlight, andat a temperature of less than 30 °C. A cool dry cupboard is satisfactory. Thestrips should only be removed from their containers one at a timeimmediately before use, and the container closed immediately.

58 SKILLS WORKSHOP 1A: GENERAL EXAMINATION AT THE FIRST ANTENATAL VISIT

K Procedure for testing urine1. The patient should pass a fresh specimen of urine. If the specimen is more

than 1 hour old the test results may be unreliable.2. The specimen should be collected in a clean, dry container.3. Dip the reagent strip in the urine so that all the reagent areas are covered,

and then remove it immediately. If the strip is left in the urine, the reagentsdissolve out of the strip, giving a false reading.

4. Draw the edge of the reagent strip across the edge of the urine container toremove excess urine, and hold the strip horizontally.

5. Hold the strip close to the colour chart on the container label (but nottouching it). It is important to compare the colours of the test strip with thoseon the chart at the correct times. Most of the test results are read between 30and 60 seconds after dipping the strip in urine:

◦ Lenstip-5: All the tests are read after 30–60 seconds.◦ Multistix: The times for reading the individual tests are on the chart.◦ Combi-9: All the tests are read after 60 seconds.

After 2 minutes the colours on the reagent strips no longer give a reliableresult.

The patient’s urine should be tested at every antenatal visit, and the resultsrecorded on the antenatal chart. Proteinuria of 1+ or more is abnormal whileglycosuria must be investigated further.

Doing a pregnancy testL Indications for a pregnancy testThis test is usually done when a patient has missed one or more menstrualperiods and when, on clinical examination, one is uncertain whether or notshe is pregnant.

The test is based on the detection of human chorionic gonadotrophin in thepatient’s urine.

The earliest that the test can be expected to be positive is 10 days afterconception. The test will be positive by the time a pregnant woman first

DOING A PREGNANCY TEST 59

misses her period. If the test is negative and the woman has not missed herperiod yet, the test should be repeated after 48 hours.

M Storage of test ‘kit’The test which is described in this unit is the U-TEST β-hCG STRIP FOIL. Ifanother pregnancy test is used, the method of doing the test and reading theresults must be carefully studied in the instruction booklet. All these kits canbe stored at room temperature. However, do not expose to direct sunlight,moisture or heat.

N Method of performing a pregnancy testThe patient should bring a fresh urine specimen.

1. Open the foil rapper and remove the test strip.2. Hold the blue end of the test strip so that the blue arrow points downwards.

Dip the test strip into the urine, as far as the point of the arrow, for 5 seconds.3. Place the test strip on a flat surface and read after 30 seconds. The result is

not reliable if the test strip is read more than 10 minutes after it was dippedinto the urine.

O Reading the result of the pregnancy test1. Negative if only the control band nearest the upper blue part of the test strip

becomes pink.2. Positive if two pink bands are visible. Between the control band and the blue

part of the test strip another pink band is seen.3. Uncertain if no pink bands are seen. Either the test was not performed

correctly or the test strip is damaged. Repeat the test with another test strip.

60 SKILLS WORKSHOP 1A: GENERAL EXAMINATION AT THE FIRST ANTENATAL VISIT

1BSkills workshop 1B:Examination of theabdomen in pregnancy

ObjectivesWhen you have completed this skills workshop you should be able to:

• Determine the gestational age from the size of the uterus.• Measure the symphysis-fundus height.• Assess the lie and the presentation of the fetus.• Assess the amount of liquor present.• Listen to the fetal heart.• Assess fetal movements.• Assess the state of fetal wellbeing.

General examination of the abdomenThere are 2 main parts to the examination of the abdomen:

1. General examination of the abdomen.2. Examination of the uterus and the fetus.

A Preparation of the patient for examination1. The patient should have an empty bladder.2. She should lie comfortably on her back with a pillow under her head. She

should not lie slightly turned to the side, as is needed when the bloodpressure is being taken.

GENERAL EXAMINATION OF THE ABDOMEN 61

B General appearance of the abdomenThe following should be specifically looked for and noted:

1. The presence of obesity.2. The presence or absence of scars. When a scar is seen the reason for it should

be specifically asked for (e.g. what operation did you have?), if this has notalready become clear from the history.

3. The apparent size and shape of the uterus.4. Any other abnormalities.

C Palpation of the abdomen1. The liver, spleen and kidneys must be specifically palpated (felt) for.2. Any other abdominal mass should be noted.3. The presence of an enlarged organ, or a mass, should be reported to the

responsible doctor, and the patient should then be assessed by the doctor.

Examination of the uterus and the fetusD Palpation of the uterus

1. Check whether the uterus is lying in the midline of the abdomen. Sometimesit is rotated to either the right or the left.

2. Feel the wall of the uterus for irregularities. An irregular uterine wallsuggests either:

◦ The presence of myomas (fibroids) which usually enlarge during pregnancyand may become painful.

◦ A congenital abnormality such as a bicornuate uterus.

62 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

E Determining the size of the uterus before 18 weeks gestation1. Anatomical landmarks are used, i.e. the symphysis pubis and the umbilicus.2. Gently palpate the abdomen with the left hand to determine the height of the

fundus of the uterus:◦ If the fundus is palpable just above the symphysis pubis, the gestational age is

probably 12 weeks.◦ If the fundus reaches halfway between the symphysis and the umbilicus, the

gestational age is probably 16 weeks.◦ If the fundus is at the same height as the umbilicus, the gestational age is

probably 22 weeks (one finger under the umbilicus = 20 weeks and one fingerabove the umbilicus = 24 weeks).

F Determining the height of the fundus from 18 weeks gestationThe symphysis-fundus height should be measured as follows:

1. Feel for the fundus of the uterus. This is done by starting to gently palpatefrom the lower end of the sternum. Continue to palpate down the abdomenuntil the fundus is reached. When the highest part of the fundus has beenidentified, mark the skin at this point with a pen. If the uterus is rotated awayfrom the midline, the highest point of the uterus will not be in the midlinebut will be to the left or right of the midline. Therefore, also palpate awayfrom the midline to make sure that you mark the highest point at which thefundus can be palpated. Do not move the fundus into the midline beforemarking the highest point.

2. Measure the symphysis-fundus (s-f) height. Having marked the fundalheight, hold the end of the tape measure at the top of the symphysis pubis.Lay the tape measure over the curve of the uterus to the point marking thetop of the uterus. The tape measure must not be stretched while doing themeasurement. Measure this distance in centimetres from the symphysis pubisto the top of the fundus. This is the symphysis-fundus height.

3. If the uterus does not lie in the midline but, for example, lies to the right, thenthe distance to the highest point of the uterus must still be measured withoutmoving the uterus into the midline.

Having determined the height of the fundus, you need to assess whether theheight of the fundus corresponds to the patient’s dates, and to the size of thefetus. From 18 weeks, the S-F height must be plotted on the SF growth curveto determine the gestational age. This method is, therefore, only used once

EXAMINATION OF THE UTERUS AND THE FETUS 63

the fundal height has reached 18 weeks. In other words when the S-F heighthas reached two fingers width under the umbilicus.

Figure 1B-1: Determining the fundal height

Figure 1B-2: Determining the uterine size before 24 weeks

64 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

Figure 1B-3: Measuring the symphysis-fundus height

G Palpation of the fetusThe lie and presenting part of the fetus only becomes important when thegestational age reaches 34 weeks.

The following must be determined:

1. The lie of the fetus. This is the relationship of the long axis of the fetus tothat of the mother. The lie may be longitudinal, transverse, or oblique.

2. The presentation of the fetus. This is determined by the presenting part:◦ If there is a breech, it is a breech presentation.◦ If there is a head, it is a cephalic presentation.◦ If no presenting part can be felt, it is a transverse or oblique lie.

3. The position of the back of the fetus. This refers to whether the back ofthe fetus is on the left or right side of the uterus, and will assist indetermining the position of the presenting part.

H Methods of palpationThere are 4 specific steps for palpating the fetus. These are performedsystematically. With the mother lying comfortably on her back, the examinerfaces the patient for the first 3 steps, and faces towards her feet for the fourth.

EXAMINATION OF THE UTERUS AND THE FETUS 65

1. First step. Having established the height of the fundus, the fundus itself isgently palpated with the fingers of both hands, in order to discover whichpole of the fetus (breech or head) is present. The head feels hard and round,and is easily movable and ballotable. The breech feels soft, triangular andcontinuous with the body.

2. Second step. The hands are now placed on the sides of the abdomen. On oneside there is the smooth, firm curve of the back of the fetus, and on the otherside the rather knobbly feel of the fetal limbs. It is often difficult to feel thefetus well when the patient is obese, when there is a lot of liquor or when theuterus is tight, as in some primigravidas.

3. Third step. The examiner grasps the lower portion of the abdomen, justabove the symphysis pubis, between the thumb and fingers of one hand. Theobjective is to feel for the presenting part of the fetus and to decide whetherthe presenting part is loose above the pelvis or fixed in the pelvis. If the headis loose above the pelvis, it can be easily moved and balloted. The head andbreech are differentiated in the same way as in the first step.

4. Fourth step. The objective of the step is to determine the amount of headpalpable above the pelvic brim, if there is a cephalic presentation. Theexaminer faces the patient’s feet, and with the tips of the middle 3 fingerspalpates deeply in the pelvic inlet. In this way the head can usually be readilypalpated, unless it is already deeply in the pelvis. The amount of the headpalpable above the pelvic brim can also be determined.

66 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

Figure 1B-4: The 4 steps in palpating the fetus

I Amount of head palpable above pelvisThe amount of head is assessed by feeling how many fifths of the head arepalpable above the brim of the pelvis:

EXAMINATION OF THE UTERUS AND THE FETUS 67

1. 5/5 of the head palpable means that the whole head is above the brim of thepelvis. A normal thyroid gland is usually slightly enlarged during pregnancy.

2. 4/5 of the head palpable means that a small part of the head is below the brimof the pelvis and can be lifted out of the pelvis with the deep pelvic grip. Anormal thyroid gland is usually slightly enlarged during pregnancy.

3. 3/5 of the head palpable means that the head cannot be lifted out of thepelvis. On doing the deep pelvic grip, your fingers will move outwards fromthe neck of the fetus, then inwards before reaching the pelvic brim.

4. 2/5 of the head palpable means that most of the head is below the pelvic brim,and on doing the deep pelvic grip, your fingers only splay outwards from thefetal neck to the pelvic brim.

5. 1/5 of the head palpable means that only the tip of the fetal head can be feltabove the pelvic brim.

Figure 1B-5: An accurate method of determining the amount of head palpableabove the brim of the pelvis

J Special points about the palpation of the fetus1. When you are palpating the fetus, always try to assess the size of the fetus

itself. Does the fetus fill the whole uterus, or does it seem to be smaller than

68 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

you would expect for the size of the uterus, and the duration of pregnancy? Afetus which feels smaller than you would expect for the duration ofpregnancy, suggests intra-uterine growth restriction, while a fetus whichfeels smaller than expected for the size of the uterus, suggests the presence ofa multiple pregnancy.

2. If you find an abnormal lie when you palpate the fetus, you should alwaysconsider the possibility of a multiple pregnancy. When you suspect that apatient might have a multiple pregnancy, she should have an ultrasoundexamination.

K Special points about the palpation of the fetal head1. Does the head feel too small for the size of the uterus? You should

always try to relate the size of the head to the size of the uterus and theduration of pregnancy. If it feels smaller than you would have expected,consider the possibility of a multiple pregnancy.

2. Does the head feel too hard for the size of the fetus? The fetal head feelsharder as the pregnancy gets closer to term. A relatively small fetus with ahard head suggests the presence of intra-uterine growth restriction.

L Assessment of the amount of liquor presentThis is not always easy to feel. The amount of liquor decreases as thepregnancy nears term. The amount of liquor is assessed clinically by feelingthe way that the fetus can be moved (balloted) while being palpated.

1. If the liquor volume is reduced (oligohydramnios), it suggests that:◦ There may be intra-uterine growth restriction.◦ There may be a urinary tract obstruction or some other urinary tract

abnormality in the fetus. This is uncommon.

2. If the liquor volume is increased (polyhydramnios), it suggests that one of thefollowing conditions may be present:

◦ Multiple pregnancy.◦ Maternal diabetes.◦ A fetal abnormality such as spina bifida, anencephaly or oesophageal atresia.

In many cases, however, the cause of polyhydramnios is unknown. However,serious problems can be present and the patient should be referred to ahospital where the fetus can be carefully assessed. The patient needs an

EXAMINATION OF THE UTERUS AND THE FETUS 69

ultrasound examination by a trained person to exclude multiple pregnancy, ora congenital abnormality in the fetus.

M Assessment of uterine irritabilityThis means that the uterus feels tight, or has a contraction, while beingpalpated. Uterine irritability normally only occurs after 36 weeks ofpregnancy, i.e. near term. If there is an irritable uterus before this time, itsuggests either that there is intra-uterine growth restriction or that thepatient may be in, or is likely to go into, preterm labour.

N Listening to the fetal heart1. Where should you listen? The fetal heart is most easily heard, by listening

over the back of the fetus. This means that the lie and position of the fetusmust be established by palpation before listening for the fetal heart.

2. When should you listen to the fetal heart? You need only listen to thefetal heart if a patient has not felt any fetal movements during the day.Listening to the fetal heart is, therefore, done to rule out an intra-uterinedeath.

3. How long should you listen for? You should listen long enough to be surethat what you are hearing is the fetal heart and not the mother’s heart. Whenyou are listening to the fetal heart, you should, at the same time, also feel themother’s pulse.

O Assessment of fetal movementsThe fetus makes 2 types of movement:

1. Kicking movements, which are caused by movement of the limbs. These areusually quick movements.

2. Rolling movements, which are caused by the fetus changing position.

When you ask a patient to count her fetal movements, she must count bothtypes of movement.

If there is a reason for the patient to count fetal movements and to recordthem on a fetal movement chart, it should be done as follows:

1. Time of day. Most patients find that the late morning is a convenient time torecord fetal movements. However, she should be encouraged to choose the

70 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

time which suits her best. She will need to rest for an hour. It is best that sheuse the same time every day.

2. Length of time. This should be for 1 hour per day, and the patient should beable to rest and not be disturbed for this period of time. Sometimes thepatient may be asked to rest and count fetal movements for 2 or more half-hour periods a day. The patient must have access to a watch or clock, andknow how to measure half- and one-hour periods.

3. Position of the patient. She may either sit or lie down. If she lies down, sheshould lie on her side. In either position she should be relaxed andcomfortable.

4. Recording of fetal movements. The fetal movements should be recordedon a chart as shown in Table 1B-6. For example, in the chart we see that:

◦ Between 08:00 and 09:00 on 3rd of July the fetus moved 6 times.◦ Between 11:00 and 12:00 on 4th July the fetus moved 9 times.◦ Between 08:00 and 09:00 on 5th July the fetus moved 3 times.

Date Time Total

3 July 8-9 6

4 July 11-12 9

5 July 8-9 3

Figure 1B-6: An example of fetal movements recorded on a fetal movementschart

All the movements should be recorded. Therefore, every time the fetus moves,the patient must make a tick on the chart. The time and day should bemarked on the chart. If the patient is illiterate, the nurse giving her the chartcan fill in the day (and times if the chart is to be used more than once a day).It is important to explain to the patient exactly how to use the chart.Remember that a patient who is resting can easily fall asleep and, therefore,miss fetal movements.

EXAMINATION OF THE UTERUS AND THE FETUS 71

P Assessment of the state of fetal wellbeingIt is very important to assess the state of fetal well being at the end of everyabdominal palpation. This is done by taking into account all the featuresmentioned in this skills workshop.

72 SKILLS WORKSHOP 1B: EXAMINATION OF THE ABDOMEN IN PREGNANCY

1CSkills workshop 1C:Vaginal examination inpregnancy

ObjectivesWhen you have completed this skills workshop you should be able to:

• List the indications for a vaginal examination.• Insert a bivalve speculum.• Perform a bimanual vaginal examination.• Take a cervical smear.

Indications for a vaginal examinationA vaginal examination is the most intimate examination a woman is eversubjected to. It must never be performed without:

1. A careful explanation to the patient about the examination.2. Asking permission from the patient to perform the examination.3. A valid reason for performing the examination.

INDICATIONS FOR A VAGINAL EXAMINATION 73

A Indications for a vaginal examination in pregnancy1. At the first visit:◦ The diagnosis of pregnancy during the first trimester.◦ Assessment of the gestational age.◦ Detection of abnormalities in the genital tract.◦ Investigation of a vaginal discharge.◦ Examination of the cervix.◦ Taking a cervical (Papanicolaou) smear.

2. At subsequent antenatal visits:◦ Investigation of a threatened abortion.◦ Confirmation of preterm rupture of the membranes with a sterile speculum.◦ To confirm the diagnosis of preterm labour.◦ Detection of cervical effacement and/or dilatation in a patient with a risk for

preterm labour, e.g. multiple pregnancy, a midtrimester abortion, previouspreterm labour or polyhyramnios.

◦ Assessment of the ripeness of the cervix prior to induction of labour.◦ Identification of the presenting part in the pelvis.◦ Performance of a pelvic assessment.

3. Immediately before labour:◦ Performance of artificial rupture of the membranes to induce labour.

B Contraindications to a vaginal examination in pregnancy1. Antepartum haemorrhage. However, there are 2 exceptions to this rule:◦ A cephalic presentation with the fetal head palpable 2/5 or less above the

pelvic brim (i.e. engaged), thereby, excluding a placenta praevia.◦ Obvious signs and symptoms of abruptio placentae.

2. Preterm and prelabour rupture of the membranes without contractions(except with a sterile speculum to confirm or exclude rupture of themembranes).

74 SKILLS WORKSHOP 1C: VAGINAL EXAMINATION IN PREGNANCY

Method of vaginal examinationC Preparation for vaginal examination

1. The bladder must be empty.2. The procedure must be carefully explained to the patient.3. The patient is put in the dorsal or lithotomy position:◦ The dorsal position is more comfortable and less embarrassing than the

lithotomy position and does not require any equipment. This is the positionmost often used.

◦ The lithotomy position provides better access to the genital tract than thedorsal position. Lithotomy poles and stirrups are required.

A vaginal examination must always be preceded by anabdominal examination.

D Examination of the vulvaThe vulva must be carefully inspected for any abnormalities, e.g. scars, warts,varicosities, congenital abnormalities, ulcers or discharge.

E Speculum examination1. A speculum examination is always performed at the first antenatal visit. At

subsequent antenatal visits this examination is only done when indicated, e.g.to investigate a vaginal discharge or in the case of preterm or prelabourrupture of the membranes.

2. The Cusco or bivalve speculum is the one commonly used.

F Insertion of a bivalve speculum1. The procedure must be explained to the patient.2. The labia are parted with the fingers of the gloved left hand.3. The patient is asked to bear down.4. The closed speculum is gently inserted posteriorly into the vagina. Great care

must be taken to avoid undue contact with the anterior vaginal wall at theintroitus as this causes great discomfort, or even pain, from pressure on theurethra.

METHOD OF VAGINAL EXAMINATION 75

5. As soon as the speculum has passed through the vaginal opening, the bladesmust be slightly opened. The speculum is now inserted deeper into thevagina. When the cervix is reached, the speculum is fully opened. Thismethod allows for inspection of the vaginal walls during insertion andensures that the cervix is found.

6. Any vaginal discharge must be identified. Where needed, a sample is takenwith a wooden spatula.

7. The vagina is inspected for congenital abnormalities such as a vaginalseptum, a vaginal stenosis or a double vagina and cervix.

8. The cervix is inspected for any laceration or tumour. A smooth, red areasurrounding the external os that retains the normal smooth surface, is normalduring the reproductive years and is called ectopy.

9. If there is a history of rupture of the membranes, the presence of liquor isnoted and tested for.

10. A cervical (Papanicolaou) smear must be taken if a smear has not been takenrecently.

11. At the end of the examination the speculum is gently withdrawn, keeping itslightly open, so that the vaginal walls can again be inspected all the way out.

G Taking a cervical smear1. A cervical (Papanicolaou) smear is taken to detect abnormalities of the cervix,

e.g. human papilloma virus infection, cervical intra-epithelial neoplasia orcarcinoma of the cervix.

2. Ideally the first cervical smear should be taken when the patient becomessexually active. In practice the first smear is usually taken when the patientfirst attends a family planning or antenatal clinic.

3. If the cervical smear is normal, it should be repeated at 30, 40 and 50 years ofage.

4. The technique of taking a cervical smear is as follows:◦ The name, folder number and date must be written on the slide with a pencil

beforehand. Also make sure that a spray can is close at hand to fix the slide.◦ A vaginal speculum is inserted.◦ The cervix must be clearly seen and is carefully inspected.◦ A suitable spatula is inserted into the cervix and rotated through 360 degrees,

making sure that the whole circumference is gently scraped. It is importantthat the smear is taken from the inside of the cervical canal as well as fromthe surface of the cervix. An Ayres (Aylesbury) or tongue spatula must be

76 SKILLS WORKSHOP 1C: VAGINAL EXAMINATION IN PREGNANCY

used and not a brush with sharp or long points such as a spatula, Cervibrushor Cytobrush.

◦ The material obtained is smeared onto a glass slide and immediately sprayedwith Papanicolaou’s fixative.

◦ When the slide is dry, it is sent to the laboratory for examination.

H Performing a bimanual examination1. First 1 and then, where possible, 2 gloved and lubricated fingers are gently

inserted into the vagina.2. If a vaginal septum or stenosis is present, the patient should be referred to a

doctor to decide whether delivery will be interfered with.3. The cervix is palpated and the following are noted:◦ Any dilatation.◦ The length of the cervix in cm, i.e. whether the cervix is effaced or not.◦ The surface should be smooth and regular.◦ The consistency which will become softer during pregnancy.

4. Special care must be taken, when performing a bimanual examination late inpregnancy and in the presence of a high presenting part, not to damage alow-lying placenta. If the latter is suspected, a finger must not be insertedinto the cervical canal. Instead, the presenting part is gently palpated throughall the fornices. If any bogginess is noted between the fingers of theexamining hand and the presenting part, the examination must beimmediately abandoned and the patient must be referred urgently forultrasonography.

5. Where possible the presenting part is identified.6. A most important part of the bimanual examination is the determination of

the gestational age, by estimating the size of the uterus and comparing it withthe period of amenorrhoea. This is only really accurate in the first trimester.Thereafter, the fundal height and the size of the fetus must be determined byabdominal examination.

7. The uterine wall is palpated for any irregularity, suggesting the presence of acongenital abnormality (e.g. bicornuate uterus) or myomata (fibroids).

8. Lastly, the fornices are palpated to exclude any masses, the commonest ofwhich is an ovarian cyst or tumour.

METHOD OF VAGINAL EXAMINATION 77

I Explanation to the patientDo not forget to explain to the patient, after the examination is completed,what you have found. It is especially important to tell her how far pregnantshe is, if that can be determined, and to reassure her, if everything appears tobe normal.

78 SKILLS WORKSHOP 1C: VAGINAL EXAMINATION IN PREGNANCY

1DSkills workshop 1D:Screening tests forsyphilis

ObjectivesWhen you have completed this skills workshop you should be able to:

• Screen a patient for syphilis with the syphilis rapid test and the RPR card test.• Interpret the results of the screening tests.

Syphilis screeningAt the first antenatal visit each woman should be screened for syphilis. Thiscan be done at the clinic with the syphilis rapid test (Determine Syphilis TP)or RPR card test. If syphilis is diagnosed the patient must be informed andtreatment must be started immediately at the antenatal clinic. Positive rapidscreening tests must be confirmed with a laboratory RPR or VDRL test. Thesyphilis rapid test or RPR card test can be used in any antenatal clinic as nosophisticated equipment is required.

Syphilis rapid testThe syphilis rapid test is a specific test for syphilis and will become positivewhen there are antibodies against Treponema pallidum (the organism thatcauses syphilis) in the blood. The test result corresponds to that of a TPHA orFTA test which are also specific tests for syphilis.

SYPHILIS RAPID TEST 79

A Equipment needed to perform a syphilis rapid test1. The Abbott Determine TB Whole Blood Essay. Each kit contains 10 cards with

10 tests. The Chase Buffer (2.5 ml bottle) is supplied with the kit.2. EDTA capillary tubes marked to indicate 50μl, lancets, alcohol swabs and

sterile gauze swabs. These are not supplied with the kit.

The kit needs to be stored at room temperature between 2 °C and 30 °C.Storage in a fridge is required during summer time. The kit must not be usedafter the expiry date.

B Performing the syphilis rapid test1. Clean a fingertip with an alcohol swab and allow the finger to dry.2. Remove a test trip from the foil cover.3. Prick the skin of the finger tip with a lancet. Wipe the first drop of blood

away with a sterile gauze swab.4. Collect the next drop of blood into the EDTA tube. Either side of the tube can

be used to collect blood. Fill the tube from the tip to the first black circle (i.e.50 μl blood). Avoid the collection of air bubbles.

5. Apply the 50 μl of blood from the EDTA tube onto the sample pad markedwith an arrow on the test strip.

6. Wait until all the blood has been absorbed into the sample pad and then applyone drop of Chase Buffer. The bottle must be held vertically (upside down)above the test strip when a drop of the buffer is dropped on the sample pad.

7. Wait a minimum of 15 minutes and then read the result. The maximumwaiting time for reading the test is 24 hours. After 24 hours the test becomesinvalid.

C Reading the results of the syphilis rapid test1. Positive: A red bar will appear within both the Control window and the

Patient window on the test strip. Any visible red bar in the Patient windowmust be regarded as positive.

2. Negative: A red bar will appear within the Control window but no red bar isseen in the Patient window.

3. Invalid: If no red bar appears in the Control window, even if a red bar isvisible in the Patient window, the result is invalid and the test must berepeated.

80 SKILLS WORKSHOP 1D: SCREENING TESTS FOR SYPHILIS

D The interpretation of the syphilis rapid test1. A positive test indicates that a person has antibodies against syphilis. This

means that the person either has active (untreated) syphilis or was infected inthe past and no longer has the disease.

2. A negative test indicates that a person does not have antibodies and cannothave syphilis, either in the present or past, unless the person was infectedvery recently and has not yet formed antibodies.

E Management if the syphilis rapid test is positive1. Explain to the patient that the screening test for syphilis is positive but that

this should be confirmed or rejected by a laboratory test (RPR or VDRL test).2. It is advisable, however, that treatment with penicillin be started immediately

so that the fetus can be treated while waiting for the result of the laboratorytest.

3. Ask the patient to return in one week for the result of the laboratory test.

F Interpretation of the RPR or VDRL test when the syphilis rapid testis positive

1. If the RPR or VDRL is negative the patient does not have syphilis. Treatmentcan be stopped.

2. If the RPR or VDRL titer is 1:16 or higher the patient has syphilis and must betreated with a full course of three doses of benzathine penicillin (Bicillin LAof Penilente LA).

3. If the RPR of VDRL titer is 1:8 or lower and woman and partner have beenfully treated in the past three months, treatment can be stopped. Otherwise afull course of three doses of benzathine penicillin must be given.

The RPR card testThe RPR card test is a non-specific test that will become positive if the patienthas syphilis. The result corresponds to that of a laboratory RPR and VDRLtest which are also non-specific tests for syphilis.

THE RPR CARD TEST 81

G Collecting a blood sampleA 3 ml sample of venous blood is needed for the test. Place the blood in a testtube for clotted blood (red topped tube).

H Equipment needed to perform a RPR card test1. The carbon antigen suspension.2. The antigen dispenser to which must be attached the special calibrated needle

with a blunt tip.3. The special stirrers (Dispenstirs).4. The white RPR card.5. The test tube holder.

Except for the test tube holder, all the necessary equipment comes with theRPR card kit.

If many tests are to be done each day and the container with the carbonantigen will be used up within 3 weeks, it is not necessary to keep thecontainer in a fridge. However, the container should be kept in a fridge if it isto be used for more than 3 weeks.

NOTEA number of different commercial companies manufacture RPR card tests. (A RPRkit can be obtained from DAVIES DIAGNOSTICS at the toll free number 0800 110509 in South Africa).

I The method of performing the RPR card test1. Keep the test tube containing 3 ml of clotted blood in an upright position. It is

important to remove the stopper when the blood is placed in the tube.2. Place the test tube in the test tube stand for 30 minutes so that the serum can

be expressed from the clotted blood.3. Use the special stirrer to transfer one drop of serum from the test tube to the

card. Squeeze the hollow stirrer between your thumb and forefinger while thetip of the stirrer is in the serum. Now relax your grip on the stirrer and asample will be sucked up.

4. Place the tip of the stirrer above the test card and again squeeze the stirrer sothat one drop falls onto the centre of the circle. If the serum of more than onepatient is tested at the same time, the test tube of clotted blood must benumbered and the same number must be written on the card with a soft pen.

82 SKILLS WORKSHOP 1D: SCREENING TESTS FOR SYPHILIS

Make sure that the number on the test tube always corresponds to thenumber on the card.

5. Using the flat end of the stirrer, spread the drop of serum over the whole areawithin the circle.

6. Shake the antigen dispenser containing the antigen suspension well. Use thedispenser with the attached calibrated needle to place one drop (50 µl) ofantigen onto the serum in the circle.

7. The card must now be gently rocked by hand so that the serum and theantigen suspension are well mixed, while the fluid on the card remains withinthe circle. If available, an electrical rotator can be used to rock the card.

8. After 4 minutes of hand rocking or 8 minutes of electronic rocking the testcan be read.

J Reading the results of the RPR card test1. A positive test: Obvious clumping takes place (flocculation). Definite black

particles form which are clearly seen with the naked eye. While the particlescover the whole area of the spread-out droplet, they tend to gather aroundthe edge of the droplet.

2. A negative test: No clumping takes place. The small black particles of thecarbon antigen tend to collect at the centre of the spread-out droplet wherethey form a black dot. They do not collect around the rim of the droplet as isseen in a positive test.

K Interpretation of the results of the RPR card test1. A positive test: Explain to the patient that the screening test for syphilis is

positive but that this should be confirmed or rejected by a laboratory test. Itis advisable, however, that treatment with penicillin be started immediatelyso that the fetus can be treated. If possible, send a sample of clotted blood tothe laboratory for a RPR or VDRL test and ask the patient to return in oneweek for the result.

2. A negative test: The patient can be reassured that she does not have syphilis.No treatment is needed. However, it is advisable that 1 out of every 20negative RPR tests be checked with a laboratory VDRL test in order thatquality control can be observed.

If it cannot be decided whether clumping of particles is present or not, asample of the patient’s blood must be sent to the laboratory for a VDRL test.

THE RPR CARD TEST 83

The patient must be seen again as soon as the results are available so that thecorrect management can be given. If the patient cannot come back for theresult or if it is not possible to get a laboratory VDRL, start treatmentimmediately.

Figure 1D-1: Examples of positive and negative tests

84 SKILLS WORKSHOP 1D: SCREENING TESTS FOR SYPHILIS

1ESkills workshop 1E:Screening tests for HIV

ObjectivesWhen you have completed this skills workshop you should be able to:

• Screen a patient for HIV using the HIV rapid test.• Interpret the results of the screening test.• Record the results of the HIV rapid test.

HIV screeningAt the first antenatal visit each woman should be offered screening for HIV.An HIV rapid test can be used in any antenatal clinic as no sophisticatedequipment is required. Prior to testing, provider-initiated counselling andconsent must be obtained.

A Equipment needed to perform an HIV rapid test1. The Abbott Determine HIV-1/2 Whole Blood Essay. Each kit contains 10 cards

with 10 tests. The Chase Buffer (2.5 ml bottle) is supplied with the kit.2. EDTA capillary tubes marked to indicate 50μl, lancets, alcohol swabs and

sterile gauze swabs. These are not supplied with the kit.

The kit needs to be stored at room temperature between 2 °C and 30 °C.Storage in a fridge is required during summer time. The kit cannot be usedafter the expiry date.

HIV SCREENING 85

B The method of performing the HIV rapid test1. Clean a fingertip with an alcohol swab and allow the finger to dry.2. Remove a test trip from the foil cover.3. Prick the skin of the fingertip with a lancet. Wipe the first drop of blood away

with a sterile gauze swab.4. Collect the next drop of blood with the EDTA tube. Either side of the tube can

be used to collect blood. Fill the tube from the tip to the first black circle (i.e.50 μl of blood). Avoid the collection of air bubbles.

5. Apply the 50 μl of blood from the EDTA tube onto the sample pad markedwith an arrow on the test strip.

6. Wait one minute until all the blood has been absorbed into the sample padand then apply one drop of Chase Buffer. The bottle must be held vertically(upside down) above the test strip when a drop of the buffer is dropped onthe sample pad.

7. Wait a minimum of 15 minutes and then read the results. The maximumwaiting time for reading the test is 24 hours. After 24 hours the test becomesinvalid.

C Reading the results of the HIV rapid test1. Positive: A red bar will appear within both the Control window and the

Patient window on the test strip. Any visible red bar in the Patient windowmust be regarded as positive. The result is positive even if the patient barappears lighter or darker than the control bar.

2. Negative: A red bar will appear within the Control window and but no redbar is seen in the Patient window.

3. Invalid: If no red bar appears in the Control window, even if a red bar isvisible in the Patient window, the result is invalid and the test must berepeated.

D The interpretation of the HIV rapid testThe test is a specific test for HIV and will become positive when there areantibodies against HIV (the virus that causes AIDS) in the blood.

86 SKILLS WORKSHOP 1E: SCREENING TESTS FOR HIV

1. A positive test indicates that a person has antibodies against HIV (HIVpositive). Therefore the person is infected with HIV.

2. A negative test indicates that a person does not have antibodies against HIV(HIV negative). Therefore the person is not infected with HIV, unless infectedvery recently and the HIV antibodies have not appeared yet.

E Management if the HIV rapid test is positive1. Explain to the patient that the first screening test for HIV is positive but that

this should be confirmed with a second test.2. Proceed with a second test using a different kit.3. If the second test is also positive, the patient is HIV positive.4. Proceed with post-test counselling for a patient with a positive test.

F Management if the first HIV rapid test is positive but the second isnegative

1. A blood sample to confirm or rule out HIV must be sent to the laboratory.2. The patient must be informed that the results of the HIV rapid tests are

inconclusive and that a laboratory test is required to finally determine herHIV status.

3. If the confirming HIV test is positive the patient is HIV positive (i.e. HIVinfected).

4. If the confirming HIV test is negative the patient is HIV negative (i.e. not HIVinfected).

5. Proceed with appropriate counselling.

G Recording the results of the rapid HIV test on the antenatal card1. If the first rapid test is negative, it is accepted that the patient is HIV

negative. In the space for special investigations on the front of the antenatalcard, ‘Yes’ must be circled if the test was accepted while precautions ‘No’must be circled as the result was negative for RVD. RVD is the abbreviationfor Retroviral Disease.

2. If both the first rapid test and the confirmatory (second) test are positive, it isaccepted that the patient is HIV positive. Circle ‘Yes’ for the test accepted andagain ‘Yes’ for precautions.

3. If, after counselling, the patient decides not to have an HIV test, test accepted‘No’ must be circled as the test was not done. Therefore there is no result.

HIV SCREENING 87

RVD: Test done Yes No Precautions Yes No

Figure 1E-1: Recording of a negative HIV test on the antenatal card

RVD: Test done Yes No Precautions Yes No

Figure 1E-2: Recording of a positive HIV test on the antenatal card

RVD: Test done Yes No Precautions Yes No

Figure 1E-3: Recording that the patient decided not to be tested for HIV

88 SKILLS WORKSHOP 1E: SCREENING TESTS FOR HIV

2Assessment of fetalgrowth and conditionduring pregnancyBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Assess normal fetal growth.• List the causes of intra-uterine growth restriction.• Understand the importance of measuring the symphysis-fundus height.• Understand the clinical significance of fetal movements.• Use a fetal movement chart.• Manage a patient with decreased fetal movements.• Understand the value of antenatal fetal heart-rate monitoring.

Introduction1. During the antenatal period, both maternal and fetal growth must be

continually monitored.2. Individualised care will improve the accuracy of antenatal observations.3. At every antenatal visit from 28 weeks gestation onwards, the wellbeing of

the fetus must be assessed.

INTRODUCTION 89

2-1 How can you assess the condition of the fetus duringpregnancy?The condition of the fetus before delivery is assessed by:

1. Documenting fetal growth.2. Recording fetal movements.

When managing a pregnant woman, remember that you arecaring for two individuals.

Fetal growth2-2 What is normal fetal growth?If the assessed fetal weight is within the expected range for the duration ofpregnancy, then the fetal growth is regarded as normal.

To determine fetal growth you must have an assessment ofboth the duration of pregnancy and the weight of the fetus.

2-3 When may fetal growth appear to be abnormal?Fetal growth will appear to be abnormal when the assessed fetal weight isgreater or less than that expected for the duration of pregnancy. Rememberthat incorrect menstrual dates are the commonest cause of an incorrectassessment of fetal growth.

2-4 When is intra-uterine growth restriction suspected?When the weight of the fetus is assessed as being less than the normal rangefor the duration of pregnancy, then intra-uterine growth restriction (fetalgrowth restriction) is suspected.

90 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

2-5 What maternal and fetal factors are associated with intra-uterine growth restriction?Intra-uterine growth restriction may be associated with either maternal, fetaland placental factors:

1. Maternal factors:◦ Low maternal weight, especially a low body mass index resulting from

undernutrition.◦ Tobacco smoking.◦ Alcohol intake.◦ Strenuous physical work.◦ Poor socio-economic conditions.◦ Pre-eclampsia and chronic hypertension.

Poor maternal weight gain is of very little value in diagnosing intra-uterinegrowth restriction.

2. Fetal factors:◦ Multiple pregnancy.◦ Chromosomal abnormalities, e.g. trisomy 21.◦ Severe congenital malformations.◦ Chronic intra-uterine infection, e.g. congenital syphilis.

3. Placental factors:◦ Poor placental function (placental insufficiency) is usually due to a maternal

problem such as pre-eclampsia.◦ Smoking.

Poor placental function is uncommon in a healthy woman who does notsmoke.

If severe intra-uterine growth restriction is present, it is essential to look for amaternal or fetal cause. Usually a cause can be found.

2-6 How can you estimate fetal weight?The following methods can be used:

1. Measure the size of the uterus on abdominal examination.2. Palpate the fetal head and body on abdominal examination.3. Measure the size of the fetus using antenatal ultrasonography (ultrasound).

FETAL GROWTH 91

2-7 How should you measure the size of the uterus?1. This is done by determining the symphysis-fundus height (S-F height), which

is measured in centimetres from the upper edge of the symphysis pubis to thetop of the fundus of the uterus.

2. The S-F height in centimetres should be plotted against the gestational age onthe S-F growth curve.

3. From 36 weeks onwards, the presenting part may descend into the pelvis andmeasurement of the S-F height will not accurately reflect the size of the fetus.A reduction in the S-F height may even be observed.

2-8 What is the symphysis-fundus growth curve?The symphysis-fundus growth curve compares the S-F height to the durationof pregnancy. The growth curve should preferably form part of the antenatalcard. The solid line of the growth curve represents the 50th centile, and theupper and lower dotted lines, the 90th and 10th centiles, respectively. If intra-uterine growth is normal, the S-F height will fall between the 10th and 90thcentiles. The ability to detect abnormalities from the growth curve is muchincreased if the same person sees the patient at every antenatal visit.

Between 18 and 36 weeks of pregnancy, the S-F height normally increases byabout 1 cm a week.

2-9 When will the symphysis-fundus height suggest intra-uterinegrowth restriction?If any of the following are found:

1. Slow increase in uterine size until one measurement falls under the 10thcentile.

2. Three successive measurements ‘plateau’ (i.e. remain the same) withoutnecessarily crossing below the 10th centile.

3. A measurement which is less than that recorded 2 visits previously withoutnecessarily crossing below the 10th centile.

Note that a measurement that was originally normal, but on subsequentexaminations has fallen to below the 10th centile, indicates intra-uterinegrowth restriction and not incorrect dates.

92 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

2-10 How can you identify severe intra-uterine growth restriction?With severe intra-uterine growth restriction, the difference between theactual duration of pregnancy and that suggested by plotting S-F height is 4weeks or more.

2-11 Does descent of the presenting part of the fetus affect yourinterpretation of the growth curve?Yes. Descent of the presenting part may occur in the last 4 weeks ofpregnancy. Therefore, after 36 weeks the above criteria are no longer valid, ifat subsequent antenatal visits progressively less of the fetal head is palpableabove the pelvic inlet.

2-12 What action would you take if the symphysis-fundus heightmeasurement suggests intra-uterine growth restriction?

1. The patient should stop smoking and rest more, while attention must begiven to her diet. It may be necessary to arrange sick leave and social supportfor the patient.

2. A poor diet which is low in energy (kilojoules) may cause intra-uterinegrowth restriction, especially in a patient with a low body mass index.Therefore, ensure that patients with suspected intra-uterine growthrestriction receive a high-energy diet. If possible, patients must be given foodsupplements (food parcels).

3. Exclude pre-eclampsia as a cause.4. If the gestational age is 28 weeks or more, careful attention must be paid to

counting the fetal movements.5. The patient should be followed up weekly at a level 1 hospital.

2-13 Which special investigation is of great value in the furthermanagement of this patient?The patient must be referred to a fetal evaluation clinic or level 2 hospital fora Doppler measurement of blood flow in the umbilical arteries:

FETAL GROWTH 93

1. Good flow (low resistance) indicates good placental function. As a result thewoman can receive further routine management as a low-risk patient.Spontaneous onset of labour can be allowed. Induction of labour at 38 weeksis not needed.

2. Poor flow (high resistance) indicates poor placental function. Antenatalelectronic fetal heart rate monitoring must be done. The further managementwill depend on the result of the monitoring.

If Doppler measurement is not available, the patient must be managed asgiven in 2-14.

2-14 What possibilities must be considered if, after taking the abovesteps, there is still no improvement in the symphysis-fundusgrowth?

1. Intra-uterine death must be excluded by the presence of a fetal heart beat onauscultation.

2. With moderate intra-uterine growth restriction and good fetal movements,the patient must be followed up weekly and delivery at 38 weeks should beconsidered.

3. If the above patient also has poor social circumstances, an admission tohospital will need to be considered. This should ensure that the patient getsadequate rest, a good diet and stops smoking.

4. If there are decreased or few fetal movements, the patient should be managedas described in sections 2-25 and 2-26.

5. When there is severe intra-uterine growth restriction, the patient must bereferred to a level 2 or 3 hospital for further management.

94 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

Figure 2-1: The symphysis-fundus growth chart

FETAL GROWTH 95

Figure 2-2: One measurement below the 10th centile

Figure 2-3: Three successive measurements that remain the same

96 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

Figure 2-4: A measurement less than that recorded 2 visits before

Fetal movements2-15 When are fetal movements first felt?

1. At about 20 weeks in a primigravida.2. At about 16 weeks in a multigravida.

2-16 Can fetal movements be used to determine the duration ofpregnancy accurately?No, because the gestational age when fetal movements are first felt differs alot from patient to patient. Therefore, it is only useful as an approximateguide to the duration of pregnancy.

FETAL MOVEMENTS 97

2-17 What is the value of assessing fetal movements?Fetal movements indicate that the fetus is well. By counting the movements, apatient can, therefore, monitor the condition of her fetus.

2-18 From what stage of pregnancy will you advise a patient tobecome aware of fetal movements in order to monitor the fetalcondition?From 28 weeks, because the fetus can now be regarded as potentially viable(i.e. there is a good chance that the infant will survive if delivered). Allpatients should be encouraged to become aware of the importance of anadequate number of fetal movements.

Asking the patient if the fetus is moving normally on the day ofthe visit is an important way of monitoring the fetal wellbeing.

2-19 What is a fetal movement chart?A fetal movement chart records the frequency of fetal movements and,thereby, assesses the condition of the fetus. The name “kick chart” is notcorrect, as all movements must be counted, e.g. rolling and turningmovements, as well as kicking.

2-20 Which patients should use a fetal movement chart?A fetal movement chart need not be used routinely by all antenatal patients,but only when:

1. There is concern about the fetal condition.2. A patient reports decreased fetal movements.

2-21 How should you advise a patient to use the fetal movementchart?Fetal movements should be counted and recorded on the chart over a periodof an hour per day after breakfast. The patient should preferably rest on herside for this period.

98 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

2-22 How accurate is a fetal movement count?A good fetal movement count always indicates a fetus in good condition. Adistressed fetus will never have a good fetal movement count. However, a lowcount or a decrease in fetal movements may also be the result of periods ofrest or sleep in a healthy fetus. The rest and sleep periods can last severalhours.

Tests with electronic equipment have shown that mothers can detect fetalmovements accurately. With sufficient motivation, the fetal movement chartcan be an accurate record of fetal movements. It is, therefore, not necessary tolisten to the fetal heart at antenatal clinics if the patient reports an adequatenumber of fetal movements, or an adequate number of fetal movements hasbeen recorded for the day.

A uterus which increases in size normally, and an activelymoving fetus, indicate that the fetus is well.

2-23 What is the least number of movements per hour whichindicates a good fetal condition?

1. The number of movements during an observation period is less importantthan a decrease in movements when compared to previous observationperiods. If the number of movements is reduced by half, it suggests that thefetus may be at increased risk of fetal distress.

2. If a fetus normally does not move much, and the count falls to 3 or fewer perhour, the fetus may be in danger.

2-24 What would you advise if the fetal movements suggest thatthe fetal condition is not good?

1. The mother should lie down on her side for another hour and repeat thecount.

2. If the number of fetal movements improves, there is no cause for concern.3. If the number of fetal movements does not improve, she should report this to

her clinic or hospital as soon as possible.

A patient who lives far away from her nearest hospital or clinic shouldcontinue with bed rest, but if the movements are 3 or fewer over a 6 hour

FETAL MOVEMENTS 99

period, then arrangements must be made for her to be moved to the nearesthospital.

2-25 What should you do if a patient arrives at the clinic or hospitalwithout a cardiotocograph (CTG machine) with reduced fetalmovements?

1. Listen to the fetal heart with a fetal stethoscope or a doptone to excludeintra-uterine death.

2. The patient should be allowed to rest and count fetal movements over a 6hour period. With 4 or more movements during the next 6 hours, repeat thefetal movement count the next day, after breakfast. If there are 3 or fewermovements over the next 6 hours, the patient should see the responsibledoctor.

The patient should be given a drink containing sugar (e.g. tea) to drink toexclude hypoglycaemia as the cause of the decreased fetal movements.

Case study 1A patient is seen at the antenatal clinic at 37 weeks gestation. She is clinicallywell and reports normal fetal movements. The S-F height was 35 cm theprevious week and is now 34 cm. The previous week the fetal head wasballotable above the brim of the pelvis and it is now 3/5 above the brim. Thefetal heart rate is 144 beats per minute. The patient is reassured that she andher fetus are healthy, and she is asked to attend the antenatal clinic again in aweek’s time.

1. Are you worried about the decrease in the S-F height since thelast antenatal visit?No, as the fetal head is descending into the pelvis. The head was 5/5 above thebrim of the pelvis and is now 3/5 above the brim.

2. What is your assessment of the fetal condition?The fetus is healthy as the S-F height is normal for 37 weeks and the fetus ismoving normally.

100 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

3. What is the value of a normal fetal heart rate during theantenatal period?The fetal heart rate is not a useful measure of the fetal condition before theonset of labour. If the fetus moves well during the antenatal period, there isno need to listen to the fetal heart.

4. What is the value of fetal movements during the antenatalperiod?Active fetal movements, noted that day, indicate that the fetus is healthy. Thepatient can, therefore, monitor the condition of her fetus by taking note offetal movements.

Case study 2You examine a 28 year old gravida 4 para 3 patient who is 34 weeks pregnant.She has no particular problems and mentions that her fetus has moved a lot,as usual, that day. The S-F height has not increased over the past threeantenatal visits but only the last S-F height measurement has fallen to the10th centile. The patient is a farm labourer and she smokes.

1. What do the S-F height measurements indicate?They indicate that the fetus may have intra-uterine growth restriction, as thelast three measurements have remained the same even though the S-F heightmeasurement has not fallen below the 10th centile.

2. What are the probable causes of the poor fundal growth?Hard physical labour and smoking. Both these factors can cause intra-uterinegrowth restriction.

3. What is the possibility of fetal distress or death in the next fewdays?Both these possibilities are most unlikely as the patient has reported normalfetal movements.

CASE STUDY 2 101

4. What can be done to improve fetal growth?Arrangements should be made, if possible, for the patient to stop working.She must also stop smoking, get enough rest and have a good diet.

5. How should this patient be managed?She must be given a fetal movement chart and you must explain clearly toher how to use the chart. She must be placed in the high-risk category and,therefore, seen at the clinic every week. If the fundal growth does notimprove, the patient must be hospitalised and labour should be induced at 38weeks.

If a Doppler blood flow measurement of the umbilical arteries indicatesnormal placental function, routine management of a low-risk patient can begiven. Induction at 38 weeks is not needed.

Case study 3A patient, who is 36 weeks pregnant with suspected intra-uterine growthrestriction, is asked to record her fetal movements on a fetal movement chart.She reports to the clinic that her fetus, which usually moves 20 times perhour, only moved 5 times during an hour that morning.

1. What should the patient have done?Rather than come to the clinic, she should have counted the number of fetalmovements for a further hour.

2. What is the correct management of this patient?She must not go home unless you are sure that her fetus is healthy. Sheshould lie on her side and count the number of fetal movements during onehour. If she has not had breakfast, give her a cold drink or a cup of sweetenedtea to make sure that she is not hypoglycaemic.

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3. What should you do if the fetus moves more than 10 times duringthe hour?If the number of fetal movements returns to more than half the previouscount (i.e. more than 10 times per hour), she can go home and return to theclinic in a week. In addition, she must count the fetal movements daily.

4. What should you do if the fetus moves fewer than 10 timesduring the hour?If the fetal movement count remains less than half the previous count, thepatient should be transferred to a hospital where antenatal electronic fetalheart monitoring can be done. Further management will depend on the resultof the monitoring.

5. What is the correct management if electronic fetal heartmonitoring is not available?Fetal movements should be counted for a full 6 hours. If the fetus movesfewer than 4 times, there is a high chance that the fetus is distressed. Adoctor must now examine the patient and decide whether the fetus should bedelivered and what would be the safest method of delivery.

CASE STUDY 3 103

Figure 2-5: The management of a patient with decreased fetal movements

104 ASSESSMENT OF FETAL GROWTH AND CONDITION DURING PREGNANCY

2ASkills workshop 2A:Routine use of theantenatal card

ObjectivesWhen you have completed this skills workshop you should be able to:

• Plot the symphysis-fundus height.• Use the symphysis-fundus height graph to assess whether the fetus is

growing adequately.

A Recording information on the antenatal cardThe front of the antenatal card is used to record details of the patient’shistory, examination, special investigations, duration of pregnancy, plannedmanagement and future family planning at the first and second antenatalvisits. The back of the antenatal card is used to record the observations madeat each antenatal visit throughout pregnancy.

The following items should be recorded on the back of the antenatal cardevery time the patient attends the antenatal clinic:

1. Date.2. Blood pressure.3. Proteinuria or glycosuria.4. Oedema.5. Fetal movements from 28 weeks onwards.6. Presenting part from 34 weeks onwards.7. Haemoglobin concentration at 28 and 36 weeks.8. The symphysis-fundus height from 18 weeks.9. Any additional notes.

10. Signature of the responsible midwife or doctor.

OBJECTIVES 105

The symphysis-fundus (SF) height and the patient’s weight are recorded onthe antenatal graph while the other information is recorded in the spacesprovided.

Figure 2A-1: The back of the antenatal card

B The significance of the lines on the graphThere are 3 oblique lines on the antenatal graph:

The 3 lines represent the normal increase in the symphysis-fundus height orSF height (i.e. a centile growth chart of fundal height). The solid line in thecentre is the 50th centile or average growth line. The dotted lines above andbelow this represent the 90th and 10th centiles respectively (i.e. the upper andlower limits of normal fundal growth).

106 SKILLS WORKSHOP 2A: ROUTINE USE OF THE ANTENATAL CARD

Figure 2A-2: A SF height measurement of 21 cm at a gestational age of 24 weeksis plotted on July 27th

C Plotting the symphysis-fundus height for the first time when thepatient is sure of the date of her last menstrual period

1. Calculate the period of gestation in weeks. The gestational age is given alongthe top and bottom of the graph (the horizontal axis).

2. Measure the SF height. The SF height in centimetre is given both sides of thegraph (the vertical axis). The patient’s SF height measures 21 cm.

3. Knowing the gestational age and the SF height, the SF height for thegestational age can be plotted on the graph and should be recorded bymaking a dot. A small circle is drawn around the dot to make sure that it isclearly seen.

OBJECTIVES 107

4. The date of the antenatal visit should be written at the top of the card in thesquare opposite the gestational age of the patient.

5. The person recording the observations on the antenatal card must also writeher or his name next to the date.

6. The method whereby the gestational age was determined must now be tickedin the appropriate block at the top left-hand corner of the chart. In this case‘Dates’ should be ticked.

7. Between 18 and 36 weeks the SF height in centimetre should be plotted onthe SF curve to determine the gestational age in weeks. If the fundal height isat the level of the umbilicus or higher, and the SF height differs from thegestational age by 4 weeks or more, the SF height should be plotted asdescribed in G.

D Plotting the SF height for the first time when the patient does notknow the date of her last menstrual period

1. The patient’s SF height measures 27 cm. Plot the measurement on the 50thcentile opposite the 27 cm on the vertical axis.

2. By plotting the SF height measurement on the 50th centile you are assumingthat the fetus is growing normally and that the measurement on thehorisontal axis represents the approximate gestational age. In this case theapproximate gestational age is 29 weeks.

3. The method whereby the gestational age was determined must now be tickedin the appropriate block at the top left-hand corner of the chart. In this case‘SF-measurement’ should be ticked.

4. The fundal growth must be carefully recorded at the following visits. If littleor no growth occurs in the next 4 weeks, the diagnosis of intra-uterinegrowth restriction must be made. If excessive growth occurs, multiplepregnancy must be excluded. Normal growth with the SF-height between the90th and 10th centiles confirms a normal growing singleton pregnancy.

108 SKILLS WORKSHOP 2A: ROUTINE USE OF THE ANTENATAL CARD

Figure 2A-3: Recording the SF height of 27 cm on the 50th centile when a patientcould not remember the date of her last menstrual period. The patient attendedthe antenatal clinic on 4th October.

OBJECTIVES 109

Figure 2A-4: A patient’s gestational age, according to her last menstrual period,is 31 weeks and the S-F height measurement is 25 cm.

E The first recording of the SF height when the duration ofpregnancy, as determined by her last normal menstrual period,differs from that determined by the SF height by 4 or more weeks.

1. According to the patient’s last menstrual period, she is 31 weeks pregnant.The SF height measurement is 25 cm which indicates a gestational age of 26weeks if plotted on the 50th centile of the SF curve.

2. In this case the fundal height is above the umbilicus, and the gestational ageestimated from the mother’s last menstrual period and the SF height differ by5 weeks. The SF height probably indicates the true gestational age. Make amark on the 50th centile opposite 25 cm. This indicates an estimatedgestational age of 26 weeks.

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3. The method by which the gestational age is estimated must be recorded in thebox at the top left-hand corner of the growth chart. In this case a tick shouldbe made opposite ‘SF measurement’.

4. The fundal growth must be carefully recorded at the following visits. If littleor no growth occurs in the next 4 weeks, the diagnosis of intra-uterinegrowth restriction must be made. If excessive growth occurs, multiplepregnancy must be excluded. Normal growth with the SF-height between the90th and 10th centiles confirms a normal growing singleton pregnancy. Thisinformation also confirms that using the SF-height to determine gestationalage was correct.

Figure 2A-5: A patient’s SF height measurement is 30 cm, 4 weeks after her lastvisit. Four weeks later the SF height is 32 cm.

OBJECTIVES 111

F Plotting the symphysis-fundus height at subsequent antenatalvisitsThe symphysis-fundus height must be plotted on the graph at everysubsequent antenatal clinic visit. As before, the symphysis-fundus heightmeasurement and the gestational age are used to determine where the dotshould be made on the graph. For example, if the patient’s present visit is 4weeks after she last attended the antenatal clinic, the S-F height measurementmust be plotted 4 weeks later on the graph.

G Recording the presenting part and the amount of fetal headpalpable above the brim of the pelvisFrom 34 weeks gestation onwards the lie and the presenting part must bedetermined at every visit (as described in Skills Workshop 1-2). Thepresenting part may be a vertex or breech. If the presenting part is a fetalhead, then the amount of head above the pelvic brim must be determined.

H Writing notes on the antenatal record cardA space is provided on the antenatal card for brief notes. A block is alsoprovided for a problem list. Few notes are needed and usually there are nonotes in patients who are assessed as being low risk with normal pregnancies.

Figure 2A-6: A problem list with short notes

112 SKILLS WORKSHOP 2A: ROUTINE USE OF THE ANTENATAL CARD

3Hypertensive disordersof pregnancyBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Define and diagnose the hypertensive disorders of pregnancy.• Give a simple classification of the hypertensive disorders of pregnancy.• Diagnose pre-eclampsia and chronic hypertension.• Explain why the hypertensive disorders of pregnancy must always be

regarded as serious.• List which patients are at risk of developing pre-eclampsia.• List the complications of pre-eclampsia.• Differentiate pre-eclampsia from severe pre-eclampsia.• Provide emergency management for a patient with pre-eclampsia.• Provide emergency management for eclampsia.• Manage gestational hypertension and chronic hypertension during

pregnancy.

The hypertensive disorders of pregnancy3-1 What is the normal blood pressure during pregnancy?The normal systolic blood pressure is less than 140 mm Hg and the diastolicblood pressure is less than 90 mm Hg.

THE HYPERTENSIVE DISORDERS OF PREGNANCY 113

3-2 What is hypertension during pregnancy?Hypertension during pregnancy is defined as a diastolic blood pressure of90 mm Hg or more and/or a systolic blood pressure of 140 mm Hg or more.

A diastolic blood pressure of 90 mm Hg or more and a systolicblood pressure of 140 mm Hg or more during pregnancy isabnormal.

During pregnancy an abnormally high blood pressure is often accompaniedby proteinuria.

3-3 What is proteinuria?Proteinuria is defined as an excessive amount of protein in the urine.Normally the urine contains no protein or only a trace of protein. Therefore, atrace of protein in the urine is not regarded as abnormal.

Proteinuria during pregnancy is diagnosed when 1+ or more protein asmeasured with a reagent strip (e.g. Albustix, Labstix, Uristix, Multistix,Lenstrip, etc).

Proteinuria during pregnancy may also be caused by:

1. A urinary tract infection.2. Renal disease.3. Contamination of the urine by a vaginal discharge.

Patients with proteinuria must be asked to collect a second sample, as amidstream specimen of urine (MSU). The correct method of collecting anMSU must be carefully explained to the patient. The amount of proteinuriapresent in the MSU must be recorded in the notes. The further managementwill be dictated by the amount of proteinuria in the MSU.

1+ or more protein in the urine is abnormal.

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3-4 What is pre-eclampsia?Pre-eclampsia presents with hypertension and proteinuria which develop inthe second half of pregnancy (20 weeks or more). Pre-eclampsia may presentduring pregnancy, labour or the puerperium.

Pre-eclampsia is also called gestational (pregnancy induced) proteinurichypertension.

3-5 What is gestational hypertension?In contrast to pre-eclampsia, gestational hypertension is not accompanied byproteinuria but also presents in the second half of pregnancy. Shouldproteinuria develop in a patient with gestational hypertension, the diagnosismust be changed to pre-eclampsia.

Pre-eclampsia presents with hypertension and proteinuria inthe second half of pregnancy.

3-6 What is chronic hypertension?Chronic hypertension is hypertension, with or without proteinuria, thatpresents during the first half of pregnancy. There is usually a history ofhypertension before the start of the pregnancy.

3-7 What is chronic hypertension with superimposed pre-eclampsia?This is hypertension presenting during the first half of pregnancy that iscomplicated by the appearance of proteinuria during the second half ofpregnancy. In other words it is chronic hypertension that is complicated bythe development of pre-eclampsia.

3-8 What is eclampsia?Eclampsia is a serious complication of pre-eclampsia that presents withconvulsions during pregnancy, labour or the first 7 days of the puerperium.Convulsions can also be the result of other causes, e.g. epilepsy, but thepossibility of eclampsia must be carefully ruled out whenever convulsionsoccur.

THE HYPERTENSIVE DISORDERS OF PREGNANCY 115

Pre-eclampsiaPre-eclampsia is the hypertensive disorder of pregnancy which occurs mostcommonly and also causes most problems for the mother and fetus.

Gestational proteinuric hypertension and chronic hypertension withsuperimposed pre-eclampsia will be discussed under the heading ‘pre-eclampsia’ because the management is similar.

3-9 How frequently does pre-eclampsia occur?In the Western Cape of South Africa 5–6% of all pregnant women developpre-eclampsia.

3-10 Is pre-eclampsia a danger to the mother?Yes, it is one of the most important causes of maternal death in most parts ofsouthern Africa.

3-11 What are the maternal complications of pre-eclampsia?The most important complications of pre-eclampsia are also important causesof maternal death during pregnancy:

1. Intracerebral haemorrhage.2. Eclampsia.

3-12 Which patients are at an increased risk of intracerebralhaemorrhage?The risk of intracerebral haemorrhage is especially high if the diastolic bloodpressure is 110 mm Hg or more and/or a systolic blood pressure of160 mm Hg or more.

3-13 Does eclampsia only occur at a very high diastolic bloodpressure?No, eclampsia can occur at a much lower blood pressure, especially in youngpatients.

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3-14 Why is pre-eclampsia a danger to the fetus and newborninfant?Pre-eclampsia is an important cause of perinatal death because:

1. Preterm delivery is often necessary because of a deterioration in the maternalcondition or the development of fetal distress.

2. Abruptio placentae is more common in patients with pre-eclampsia and oftenresults in an intra-uterine death.

3. Pre-eclampsia is associated with decreased placental blood flow. As a result ofdecreased placental blood flow the fetus may suffer from:

◦ Intra-uterine growth restriction or wasting.◦ Fetal distress.

Pre-eclampsia may result in intra-uterine growth restriction,fetal distress, preterm delivery and intra-uterine death.

3-15 How can the severity of pre-eclampsia be graded?The severity of pre-eclampsia can be graded by:

1. The diastolic blood pressure and/or systolic.2. The amount of proteinuria.3. Signs and symptoms of imminent eclampsia.4. The presence of convulsions.

Patients with pre-eclampsia can be divided into 4 grades of severity:

1. Pre-eclampsia. A diastolic blood pressure of 90 to 109 mm Hg andproteinuria, and/or a systolic blood pressure of 140 to 159 mm Hg, plusproteinuria.

2. Severe pre-eclampsia. Any of the following:◦ A diastolic blood pressure of 110 mm Hg or more and/or a systolic blood

pressure of 160 mm Hg or more on 2 occasions, 4 hours apart, plusproteinuria.

◦ A diastolic blood pressure of 120 mm Hg or more and/or a systolic bloodpressure of 170 mm Hg or more on 1 occasion, plus proteinuria.

3. Imminent eclampsia. These patients have symptoms and/or signs thatindicate that they are at extremely high risk of developing eclampsia at any

PRE-ECLAMPSIA 117

moment. The diagnosis does not depend on the degree of hypertension or theamount of proteinuria present.

4. Eclampsia: Eclampsia is diagnosed when a patient with any of the grades ofpre-eclampsia has a convulsion.

If there is any doubt about the grade of pre-eclampsia, thepatient should always be placed in the more severe grade.

Patients who improve on bed rest should be kept in the grade of pre-eclampsia which they were given at the initial evaluation. Furthermanagement should be in accordance with this grade.

3-16 What are the symptoms and signs of imminent eclampsia?The symptoms are:

1. Headache.2. Visual disturbances or flashes of light seen in front of the eyes.3. Upper abdominal pain, in the epigastrium and/or over the liver.

The signs are:

1. Tenderness over the liver.2. Increased tendon reflexes, e.g. knee reflexes.

The diagnosis of imminent eclampsia is made even if only oneof the symptoms or signs is present, irrespective of the bloodpressure or the amount of proteinuria.

3-17 How common is eclampsia?In the Western Cape of South Africa the incidence of eclampsia is 1 per 1000pregnancies.

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Patients at increased risk of pre-eclampsia3-18 Which patients are at an increased risk of pre-eclampsia?

1. Primigravidas.2. Patients with chronic hypertension.3. Patients over 34 years.4. Patients with a multiple pregnancy.5. Diabetics.6. Patients with a past history of a pregnancy complicated by pre-eclampsia,

especially if the pre-eclampsia developed during the late 2nd or early 3rdtrimester.

7. Patients who develop generalised oedema, especially facial oedema.

3-19 What advice should be given to patients at increased risk ofpre-eclampsia?They must be told about the symptoms of imminent eclampsia, and advised tocontact the clinic or hospital immediately, if these symptoms appear.

3-20 What special care should be given to patients at increased riskof pre-eclampsia?In the second half of pregnancy, the following must be carefully watched for:

1. A rise in diastolic blood pressure.2. Proteinuria.3. Symptoms and signs of imminent eclampsia.

Patients with an obstetric history of pre-eclampsia that developed late in thesecond or early in the third trimester, must receive 75 mg aspirin (a quarterDisprin) daily from a gestational age of 14 weeks. This will reduce the riskthat pre-eclampsia may develop.

PATIENTS AT INCREASED RISK OF PRE-ECLAMPSIA 119

3-21 What should you do if a patient develops generalised oedema,but remains normotensive and does not have proteinuria?

1. She should rest as much as possible.2. She should be followed up weekly at the antenatal clinic and carefully

checked for the development of hypertension and proteinuria.3. She should carefully monitor the fetal movements.

The management of pre-eclampsia3-22 What should you do if a patient develops pre-eclampsia?

1. A patient with pre-eclampsia must be admitted to hospital. Such a patientmay safely be cared for in a level 1 hospital.

2. Methyldopa (Aldomet) must be prescribed to control the blood pressure.

All patients with pre-eclampsia must be admitted to hospital,irrespective of the level of the blood pressure.

The emergency management of severe pre-eclampsia and imminent eclampsiaThe management of patients with severe pre-eclampsia and imminenteclampsia is the same and consists of stabilising the patient, followed byreferral to a level 2 or 3 hospital.

3-23 What are the two greatest dangers to the patient with severepre-eclampsia?The two greatest dangers, which are a threat to the patient’s life, areeclampsia and an intracerebral haemorrhage.

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3-24 How should you manage a patient with severe pre-eclampsiaor imminent eclampsia?The main aims of management are to:

1. Prevent eclampsia, by giving magnesium sulphate.2. Prevent intracerebral haemorrhage, by decreasing the blood pressure with

oral nifedipine capsules (Adalat) or parenteral dihydralazine (Nepresol).

The initial management of severe pre-eclampsia and imminenteclampsia is aimed at the prevention of eclampsia andintracerebral haemorrhage.

The steps in the management of severe pre-eclampsia are:

Step 1An intravenous infusion is started (Balsol or Ringer’s lactate) and magnesiumsulphate is administered as follows:

1. Give 4 g slowly intravenously over 10 minutes. Prepare the 4 g by adding 8ml 50% magnesium sulphate (i.e. 2 ampoules) to 12 ml sterile water.

2. Then give 5 g (i.e. 10 ml 50% magnesium sulphate) by deep intramuscularinjection into each buttock.

A total of 14 g of magnesium sulphate is, therefore, given.

Step 2After the magnesium sulphate has been administered, a Foley’s catheter isinserted into the patient’s bladder, to monitor the urinary output.

Step 3After giving the magnesium sulphate the blood pressure must be measuredagain. Magnesium sulphate may cause a slight drop in blood pressure. If thediastolic blood pressure is still 110 mg Hg or more and/or the systolic bloodpressure 160 mm Hg or more, oral nifedipine (Adalat) or dihydralazine(Nepresol) is given as follows:

THE EMERGENCY MANAGEMENT OF SEVERE PRE-ECLAMPSIA AND IMMINENT ECLAMPSIA 121

1. Give 10 mg (one capsule) nifedipine orally or 6.25 mg dihydralazine byintramuscular injection.

2. The patient’s blood pressure is taken every 5 minutes for the next 30 minutes.3. If the blood pressure drops too much, intravenous Balsol or Ringer’s lactate is

administered rapidly, until the blood pressure returns to normal.4. If the blood pressure does not drop, patients who have received 10 mg

nifedipine can be given a second dose of 10 mg nifedipine orally if thediastolic blood pressure remains 110 mm Hg or more or a systolic bloodpressure of 160 mm Hg or more after 30 minutes. If necessary, 10 mgnifedipine orally can be repeated half hourly up to a maximum dose of 50 mg.

Or

If dihydralazine was used, an ampoule of dihydralazine (25 mg) should bemixed with 20 ml of sterile water. Bolus doses of 2 ml (2.5 mg) are then givenslowly intravenously at 20 minute intervals until the diastolic blood pressuredrops below 110 mm Hg.

Nifedipine 10 mg capsules must always be given orally in pregnancy and notgiven sublingually (under the tongue). The 10 mg capsules must not beconfused with Adalat XL tablets which are slowly dissolved and not suitablefor rapidly lowering the blood pressure.

Step 4When the blood pressure is controlled, the patient is transferred to a level 2or 3 hospital.

Patients with severe pre-eclampsia or imminent eclampsiamust always be stabilised before they are transferred.

3-25 What can be done to ensure maximal safety for the patientduring her transfer to hospital?

1. A doctor or registered nurse/midwife should accompany the patient.2. Resuscitation equipment, together with magnesium sulphate, calcium

gluconate and nifedipine or dihydralazine, must be available in theambulance. Respiration may be depressed if a large dose of magnesium

122 HYPERTENSIVE DISORDERS OF PREGNANCY

sulphate is given too rapidly. Calcium gluconate is the antidote to be given inthe event of an overdose of magnesium sulphate.

3. Convulsions must be watched for and the patient’s blood pressure must alsobe carefully observed.

4. If the patient begins to convulse in the ambulance, she must be given afurther 2 g of magnesium sulphate intravenously. The dose may, if required,be repeated once. (Make up the solution beforehand and keep it ready in a 20ml syringe). Further maintenance doses of magnesium sulphate must begiven if more than 4 hours pass after the loading dose.

5. If the blood pressure again rises to 110 mm Hg or more while the patient isbeing transported, you should give a second dose of 10 mg nifedipine bymouth or 6.25 mg dihydralazine intramuscularly. Remember that, with everyadministration of dihydralazine, there is a danger that the patient maybecome hypotensive. Another side-effect is tachycardia, and if the pulse raterises to 120 beats per minute or above, further administration ofdihydralazine must be stopped.

The management of eclampsia3-26 What is your immediate management if a patient convulses?The management of eclampsia is as follows:

Step 1Prevent aspiration of the stomach contents by:

• Turning the patient immediately on her side.• Keeping the airway open by suctioning (if necessary) and inserting an

airway.• Administering oxygen.

Step 2Stop the convulsion and prevent further convulsions by putting up anintravenous infusion of Balsol or Ringer’s lactate and giving magnesiumsulphate.

THE MANAGEMENT OF ECLAMPSIA 123

Step 3After the magnesium sulphate has been given, insert a Foley’s catheter tomonitor the urinary output.

Step 4If the diastolic blood pressure is 110 mm Hg or more and/or the systolic bloodpressure 160 mm Hg or more, it must be reduced with dihydralazine(Nepresol). Oral nifedipine can be used if the patient is fully conscious afterthe convulsion.

Step 5The patient must now be urgently transferred to a level 2 or 3 hospital.

Eclampsia is a life-threatening condition for both the motherand the fetus. Immediate management is, therefore, needed.

3-27 What should you do if the patient convulses again?If the patient convulses again, after the convulsions had initially beencontrolled by the total loading dose of 14 g of magnesium sulphate, a further2 g of magnesium sulphate should be administered intravenously. This dosecan be repeated once more in the unlikely event of the patient having yet afurther convulsion.

Gestational hypertension3-28 What should you do if a patient develops gestationalhypertension?A patient with a slightly elevated blood pressure (a diastolic blood pressure of90 to 95 mm Hg), which develops in the second half of pregnancy, in theabsence of proteinuria, may be managed in a level 1 hospital or clinic. If thehome circumstances are poor, she must be admitted to hospital, for bedrest.Where the home circumstances are good, the patient is allowed bedrest athome, under the following conditions:

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1. The patient must be told about the symptoms of imminent eclampsia. Shouldany of these occur, she must contact or attend the hospital or clinicimmediately.

2. The patient must be seen weekly at a high-risk antenatal clinic. In addition,following the initial diagnosis, she must be seen once between visits, to checkthe blood pressure and test the urine for protein.

3. If the patient cannot be seen more frequently, she must be given urinaryreagent strips to take home. She must then test her urine daily and go to theclinic, should there be 1+ proteinuria or more.

4. No special investigations are indicated.5. Alpha methyldopa (Aldomet) must be prescribed to control the blood

pressure. The initial dosage is 500 mg 8 hourly.

Patients with a diastolic blood pressure of 100 mm Hg or more and/or asystolic blood pressure of 160 mm Hg or more must be admitted to hospitaland alpha methyldopa (Aldomet) must be prescribed. Once the diastolic bloodpressure has dropped below 100 mm Hg and the systolic blood pressure tobelow 160 mm Hg, they are managed as indicated above.

3-29 How should you monitor the fetus, in order to ensure fetalwellbeing?Fetal movements must be counted and recorded twice daily. If available thepatient should be referred for a Doppler measurement of the blood flow in theumbilical artery to determine placental function.

3-30 When should you deliver a patient with gestationalhypertension?If the blood pressure remains well controlled, no proteinuria develops and thefetal condition remains good, the pregnancy must be allowed to continueuntil 40 weeks when induction of labour must be done.

Chronic hypertensionThese patients have hypertension in the first half of pregnancy, or are knownto have had hypertension before the start of pregnancy. They do not havesuperimposed pre-eclampsia.

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3-31 Which patients with chronic hypertension should be referredto a level 2 or 3 hospital?A good prognosis can be expected if:

1. Renal function is normal (normal serum creatinine concentration).2. Pre-eclampsia is not superimposed on the chronic hypertension.3. The blood pressure is well controlled (a diastolic blood pressure of 90 mm Hg

or less and a systolic blood pressure of 140 mm Hg or less) from early inpregnancy.

Therefore, these women can be managed at a level 1 hospital. However,women with chronic hypertension should be referred to a level 2 or 3 hospitalfor further management if:

1. Renal function is abnormal (serum creatinine more than 120 mmol/l).2. Proteinuria develops.3. The diastolic blood pressure is 110 mm Hg or higher more and systolic blood

pressure 160 mm Hg or more.4. There is intra-uterine growth restriction.5. More than one drug is required to control the blood pressure.

3-32 Will you adjust the medication of a patient with chronichypertension when she becomes pregnant?Yes, she must be put onto alpha methyldopa (Aldomet) 500 mg 8 hourly.Other antihypertensives (i.e. diuretics, beta blockers and ACE inhibitors)must be stopped.

3-33 What special care is needed for a patient with chronichypertension during pregnancy?

1. Any rise in the blood pressure or the development of proteinuria must becarefully looked for, as they indicate an urgent need for referral.

2. A Doppler measurement of the blood flow in the umbilical artery todetermine placental function should be done.

3. Postpartum sterilisation must be discussed with the patient, and isrecommended when the patient is a multigravida.

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3-34 When should you deliver a patient with chronic hypertension?The management is the same as that for gestational hypertension.

Case study 1A 21 year old primigravid patient has attended the antenatal clinic and herpregnancy progresses normally to 33 weeks. At the next visit at 35 weeks, thepatient complains that her hands and feet have started to swell over the pastweek. On examination, you notice that her face is also slightly swollen. Herblood pressure is 120/80, which is the same as at her previous visit, and shehas no proteinuria. She reports that her fetus moves frequently.

1. Why is this patient at high risk of developing pre-eclampsia?Because she is a primigravida and has developed generalised oedema over thepast week.

2. How should this patient be managed further?She should rest a lot. She also should be seen at the antenatal clinic again in aweek when she must be carefully examined for a rise in blood pressure or thepresence of proteinuria.

3. What advice should this patient be given?She should be told about the symptoms of imminent eclampsia, i.e. headache,flashes of light before the eyes, and upper abdominal pain. She should also beasked to count and record fetal movements twice a day. If any of the above-mentioned symptoms are experienced, or if fetal movements decrease, shemust immediately report to the clinic or hospital.

4. When you see the patient a week later she has a diastolic bloodpressure of 90 mm Hg, but there is still no proteinuria. How shouldshe be managed further?The patient has pregnancy-induced hypertension. If the home conditions aresatisfactory, she can be managed with bedrest at home. The hypertensionmust be controlled with alpha methyldopa (Aldomet). She must be seen twice

CASE STUDY 1 127

a week, and carefully monitored, to detect a rise in the blood pressure and thepossible development of proteinuria. If the blood pressure rises and/orproteinuria develops, she must be referred to hospital for admission. If thehome conditions are poor, she should be admitted to hospital for bed rest.

Case study 2At an antenatal clinic you see a patient who is 39 weeks pregnant. Up untilnow she has had a normal pregnancy. On examination, you find that herdiastolic blood pressure is 95 mm Hg and that she has 2+ proteinuria.

1. How should this patient be managed?She should be transferred to hospital as all patients with 2+ proteinuria mustbe hospitalised.

2. On examining this patient you observe that she has increasedpatellar reflexes, i.e. brisk knee jerks. How should this observationalter her management?Increased tendon reflexes are a sign of imminent eclampsia. The diagnosismust be made, irrespective of the degree of hypertension or the amount ofproteinuria. To prevent the development of eclampsia, the patient must begiven magnesium sulphate.

3. What is the danger to this patient’s health?The patient has severe pre-eclampsia. Therefore, the immediate danger to herlife is the development of eclampsia or an intracerebral haemorrhage.

4. How should this patient be managed?Her clinical condition must first be stabilised. An intravenous infusion shouldbe started and a loading dose of 14 g magnesium sulphate must be given. Thisshould prevent the development of eclampsia. A Foley’s catheter must beinserted in her bladder.

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5. Is a loading dose of magnesium sulphate also adequate tocontrol the high blood pressure?No. Sometimes with severe pre-eclampsia, the diastolic blood pressure willdrop to below 110 mm Hg after a loading dose of magnesium sulphate hasbeen given. In that case, no further management is needed for thehypertension. However, if the patient’s blood pressure does not drop afteradministering the magnesium sulphate, 10 mg (one capsule) oral nifedipine(Adalat) or intramuscular dihydralazine (Nepresol) 6.25 mg should be given.

Case study 3While working at a level 1 hospital you admit a patient with a diastolic bloodpressure of 120 mm Hg and 3+ proteinuria. She is 32 weeks pregnant. Onfurther questioning and examination she has no symptoms or signs ofimminent eclampsia.

1. What is the danger to this patient’s health?The patient has severe pre-eclampsia. Therefore, the immediate danger to herlife is the development of eclampsia or an intracerebral haemorrhage.

2. How should this patient be managed?Her clinical condition must first be stabilised. An intravenous infusion shouldbe started and a loading dose of 14 g magnesium sulphate must be given. Thisshould prevent the development of eclampsia.

3. Is a loading dose of magnesium sulphate also adequate tocontrol the high blood pressure?No. Sometimes, the diastolic blood pressure will drop to below 110 mm Hgafter a loading dose of magnesium sulphate has been given. In that case, nofurther management is needed for the hypertension. However, if the patient’sblood pressure does not drop after administering the magnesium sulphate,intramuscular dihydralazine (Nepresol) 6.25 mg or 10 mg (one capsule) oralnifedipine (Adalat) should be given.

CASE STUDY 3 129

4. Should you continue to manage this patient at a level 1 hospital?No. The patient should be transferred to a level 2 or 3 hospital, for furthermanagement. Both severe pre-eclampsia and the gestational age (32 weeks) atwhich the complications developed are reasons for management at least in alevel 2 hospital.

Case study 4A 37 year old, gravida 4, para 3 patient books for antenatal care. She haschronic hypertension and is managed with a diuretic. By dates andexamination she is 14 weeks pregnant.

1. Should the management of the patient’s hypertension bechanged during the pregnancy?Yes. The diuretic should be stopped, as these drugs are not completely safeduring pregnancy. Instead, the patient should be treated with alphamethyldopa (Aldomet).

2. What factors indicate a good prognosis for a patient with chronichypertension during pregnancy?Normal renal function, no superimposed pre-eclampsia and good control ofthe blood pressure during pregnancy.

3. How can superimposed pre-eclampsia be diagnosed duringpregnancy?The patient will develop proteinuria and/or a rise in blood pressure duringthe second half of pregnancy.

4. Why is it important to detect superimposed pre-eclampsia in apatient with chronic hypertension?Because the risk of complications increases. As a result a preterm deliverymay be necessary. The patient should, therefore, be transferred to a level 2 or3 hospital if superimposed pre-eclampsia develops.

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5. What should be seriously recommended during the puerperiumin this patient?A postpartum sterilisation. Postpartum sterilisation should be discussed withthe patient during the pregnancy. Postpartum sterilisation is particularlyimportant as the patient is a 37 year old multipara with chronic hypertension.

CASE STUDY 4 131

3ASkills workshop 3A:Measuring bloodpressure and proteinuria

ObjectivesWhen you have completed this skills workshop you should be able to:

• Measure the blood pressure.• Measure the amount of protein in the urine.

Measuring blood pressureA The standardised method of measuring blood pressureThe following are important if you want to measure the blood pressureaccurately:

1. The right upper arm is used.2. The arm must be taken out of the sleeve.3. The patient should lie on her right side with a 30 degree lateral tilt or sit in a

chair.4. Take the blood pressure after a 5 minute period of rest.5. The cuff must be applied correctly. If the patient is sitting in a chair, the blood

pressure apparatus must be at the same level as her upper arm.6. The systolic blood pressure is taken at Korotkoff phase 1.7. The diastolic blood pressure is taken at Korotkoff phase 5.

The patient should lie on her right side or sit when her bloodprerssure is measured.

132 SKILLS WORKSHOP 3A: MEASURING BLOOD PRESSURE AND PROTEINURIA

B Use the right armThe examination couches in most clinics stand with their left side against awall as it is most convenient for a right-handed person to examine the rightside of the patient. The lower arm (i.e. the right arm if she is lying on herright side) should be used, as the upper arm will give false low readings as itis above the level of the heart. The arm must be fully undressed so that thecuff can be correctly applied.

C The patient must not lie on her backThe patient should lie down on her side or sit. Lying on her back may causehypotension, giving a falsely low reading. She should also lie slightly turnedonto her side. Lying on her back may cause the uterus to press on the inferiorvena cava resulting in a decreased return of blood to the heart and a drop inblood pressure. A false low blood pressure may, therefore, be recorded.

D Allow the patient to rest for 5 minutes before measuring theblood pressureAnxiety and the effort of climbing onto the couch often increases the bloodpressure. This will usually return to a resting value if the patient can lie downand relax for 5 minutes.

E How to apply the cuffA standard size cuff (width of 14.5 cm) is usually used. If the arm is very fat,then use a wide cuff (17.5 cm) to get a correct reading. The cuff must beapplied firmly around the arm, not allowing more than 1 finger between thecuff and the patient’s arm.

F Listening to the pulseThe cuff should be pumped up with a finger feeling the brachial or radialpulse. Only when the pulse can no longer be felt, should the stethoscope beput over the brachial pulse and the pressure released slowly.

G Recognising the Korotkoff phases 1 and 5The Korotkoff phases are times when the sound of the pulse changes duringthe measurement of the blood pressure:

MEASURING BLOOD PRESSURE 133

Phase 1 is the first sound which you hear after the cuff pressure is released.This indicates the systolic pressure.

Phase 5 is the time when the sound of the pulse disappears. Usually thesound gets softer before it disappears but sometimes it disappears withoutfirst becoming softer at the same time. However, in all cases the diastolicblood pressure must be read when the sound of the pulse disappears.

Measuring proteinuriaH Measuring the amount of proteinuriaThe amount of protein in a sample of urine is simply and easily measuredwith a plastic, reagent strip.

I Grading the amount of proteinuriaUsing a reagent strip the amount of proteinuria is graded as follows:

• 1+ = 0.3 g/l• 2+ = 1.0 g/l• 3+ = 3.0 g/l• 4+ = 10 g/l

Remember that a trace (0.1g/l) of protein is not regarded as significantproteinuria and may occur normally.

J The use of a reagent strip to measure the amount of proteinuria1. Collect a fresh specimen of urine.2. Remove a reagent strip from the bottle and replace the cap.3. Dip the strip into the urine so that all the test areas are completely covered,

then immediately remove the strip.4. Wait 60 seconds.5. Hold the strip horizontally and compare with the colour blocks on the side of

the bottle. Hold the strip close to the bottle to match the colours but do notrest it on the bottle as the urine will damage the colour chart. The darker thecolour of the reagent strip, the greater is the amount of proteinuria.

134 SKILLS WORKSHOP 3A: MEASURING BLOOD PRESSURE AND PROTEINURIA

K Reagent strips can give a false readingReagent strips may incorrectly assess the degree of proteinuria if the urine isvery concentrated or very dilute. Do not use the first urine passed in themorning as it may be concentrated and, therefore, give a falsely high reading.

MEASURING PROTEINURIA 135

4AntepartumhaemorrhageBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Understand why an antepartum haemorrhage should always be regarded asserious.

• Provide the initial management of a patient presenting with an antepartumhaemorrhage.

• Diagnose the most likely cause of the bleeding from the history andexamination of the patient.

• Know how to manage a patient with a slight vaginal bleed mixed with mucus.• Diagnose the cause of a blood-stained vaginal discharge and provide

appropriate treatment.

Antepartum haemorrhage4-1 What is an antepartum haemorrhage?An antepartum haemorrhage is any vaginal bleeding which occurs at or after24 weeks (estimated fetal weight at 24 weeks = 500 g) and before the birth ofthe infant. A bleed before 28 weeks is regarded as a threatened miscarriage asthe fetus is usually considered not to be viable.

136 ANTEPARTUM HAEMORRHAGE

4-2 Why is an antepartum haemorrhage such a serious condition?1. The bleeding can be so severe that it can endanger the life of both the mother

and fetus.2. Abruptio placentae is a common cause of antepartum haemorrhage and an

important cause of perinatal death in many communities.

Therefore, all patients who present with an antepartum haemorrhage must beregarded as serious emergencies until a diagnosis has been made. Furthermanagement will depend on the cause of the haemorrhage.

Any vaginal bleeding during pregnancy may be an importantdanger sign that must be reported immediately.

4-3 What advice about vaginal bleeding should you give to allpatients?Every patient must be advised that any vaginal bleeding is potentially seriousand told that this complication must be reported immediately.

4-4 What is the management of an antepartum haemorrhage?The management consists of 4 important steps that should be carried out inthe following order:

1. The maternal condition must be evaluated and stabilised, if necessary.2. The condition of the fetus must then be assessed.3. The cause of the haemorrhage must be diagnosed.4. Finally, the definitive management of an antepartum haemorrhage,

depending on the cause, must be given.

It must also be decided whether the patient should be transferred for furthertreatment.

The initial, emergency management ofantepartum haemorrhageThe management must always be provided in the following order:

THE INITIAL, EMERGENCY MANAGEMENT OF ANTEPARTUM HAEMORRHAGE 137

1. Assess the condition of the patient. If the patient is shocked, she must beresuscitated immediately.

2. Assess the condition of the fetus. If the fetus is viable but distressed, anemergency delivery is needed.

3. Diagnose the cause of the bleeding, taking the clinical findings into accountand, if necessary, the results of special investigations.

4-5 What symptoms and signs indicate that the patient is shockeddue to blood loss?

1. Dizziness is the commonest symptom of shock.2. On general examination the patient is sweating, her skin and mucous

membranes are pale, and she feels cold and clammy to touch.3. The blood pressure is low and the pulse rate fast.

4-6 How should you manage a shocked patient with an antepartumhaemorrhage?When there are symptoms and signs to indicate that the patient is shocked,you must:

1. Put up two intravenous infusions (‘drips’) with Balsol or Ringer’s lactate, torun in quickly in order to actively resuscitate the patient.

2. Insert a Foley’s catheter into the patient’s bladder, to measure the urinaryvolume and to monitor further urine output.

3. If blood is available, take blood for cross-matching at the time of putting upthe intravenous infusion and order 2 or more units of blood urgently.

4. Refer the patient to the hospital.

4-7 What must you do if a patient presents with a life-threateninghaemorrhage?The maternal condition takes preference over that of the fetus. The patient,therefore, is actively resuscitated while arrangements are made to transferthe patient to the hospital. At the hospital an emergency caesarean section orhysterotomy will be performed.

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Diagnosing the cause of the bleeding4-8 Should you treat all patients with antepartum haemorrhage inthe same way, irrespective of the amount and character of thebleed?No. The management differs depending on whether the vaginal bleeding isdiagnosed as a ‘haemorrhage’ on the one hand, or a blood-stained vaginaldischarge or a ‘show’ on the other hand. A careful assessment of the amountand type of bleeding is, therefore, very important.

1. Any vaginal bleeding at or after 24 weeks must be diagnosed as anantepartum haemorrhage if any of the following are present:

◦ A sanitary pad is at least partially soaked with blood.◦ Blood runs down the patient’s legs.◦ A clot of blood has been passed.

A diagnosis of a haemorrhage always suggests a seriouscomplication.

2. A blood-stained vaginal discharge will consist of a discharge mixed with asmall amount of blood.

3. A ‘show’ will consist of a small amount of blood mixed with mucus. Theblood-stained vaginal discharge or ‘show’ will be present on the surface ofthe sanitary pad but will not soak it.

If the maternal and fetal conditions are satisfactory, then a careful speculumexamination should be done to exclude a local cause of the bleeding. Do NOTperform a digital vaginal examination, as this may cause massivehaemorrhage if the patient has a placenta praevia.

Do not do a digital vaginal examination until placenta praeviahas been excluded.

DIAGNOSING THE CAUSE OF THE BLEEDING 139

4-9 How does a speculum examination help you determine thecause of the bleeding?

1. Bleeding through a closed cervical os confirms the diagnosis of ahaemorrhage.

2. If the cervix is a few centimetres dilated with bulging membranes, or thepresenting part of the fetus is visible, this suggests that the bleed was a‘show’.

3. A blood-stained discharge in the vagina, with no bleeding through thecervical os, suggests a vaginitis.

4. Bleeding from the surface of the cervix caused by contact with the speculum(i.e. contact bleeding) may indicate a cervicitis or cervical intra-epithelialneoplasia (CIN).

5. Bleeding from a cervical tumour or an ulcer may indicate an infiltratingcarcinoma.

4-10 Can you rely on clinical findings to determine the cause of ahaemorrhage?In many cases the history and examination of the abdomen will enable thepatient to be put into one of 2 groups:

1. Abruptio placentae (placental abruption).2. Placenta praevia.

There are some patients in whom no reason for the haemorrhage can befound. Such a haemorrhage is classified as an antepartum haemorrhage ofunknown cause.

4-11 What is the most likely cause of an antepartum haemorrhagewith fetal distress?Abruptio placentae is the commonest cause of antepartum haemorrhageleading to fetal distress or an intra-uterine death. However, sometimes theremay be very little or no bleeding even with a severe abruptio placentae.

An antepartum haemorrhage with fetal distress or fetal death isalmost always due to abruptio placentae.

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4-12 What is the most likely cause of a life-threatening antepartumhaemorrhage?A placenta praevia is the most likely cause of a massive antepartumhaemorrhage that threatens the woman’s life.

Antepartum bleeding caused by abruptioplacentae4-13 What is abruptio placentae?Abruptio placentae (placental abruption) means that part or all of a normallyimplanted placenta has separated from the uterus before delivery of the fetus.The cause of abruptio placentae remains unknown.

4-14 Which patients are at increased risk of abruptio placentae?Patients with:

1. A history of an abruptio placentae in a previous pregnancy. (There is a 10%chance of recurrence after an abruptio placentae in a previous pregnancy anda 25% chance after 2 previous pregnancies with an abruptio placentae.)

2. Pre-eclampsia (gestational proteinuric hypertension), and to a lesser extentany of the other hypertensive disorders of pregnancy.

3. Intra-uterine growth restriction.4. Cigarette smoking.5. Poor socio-economic conditions.6. A history of abdominal trauma, e.g. a fall or kick on the abdomen.

4-15 What symptoms point to a diagnosis of abruptio placentae?1. An antepartum haemorrhage which is associated with continuous, severe

abdominal pain.2. A history that the blood is dark red with clots.3. Absence of fetal movements following the bleeding.

ANTEPARTUM BLEEDING CAUSED BY ABRUPTIO PLACENTAE 141

4-16 What do you expect to find on examination of the patient?1. The general examination and observations show that the patient is shocked,

often out of proportion to the amount of visible blood loss.2. The patient usually has severe abdominal pain.3. The abdominal examination shows the following:◦ The uterus is tonically contracted, hard and tender, so much so that the whole

abdomen may be rigid.◦ Fetal parts cannot be palpated.◦ The uterus is bigger than the patient’s dates suggest.◦ The haemoglobin concentration is low, indicating severe blood loss.

4. The fetal heart beat is almost always absent in a severe abruptio placentae.

These symptoms and signs are typical of a severe abruptio placentae.However, abruptio placentae may present with symptoms and signs whichare less obvious, making the diagnosis difficult.

The diagnosis of severe abruptio placentae can usually be madefrom the history and physical examination.

Antepartum bleeding caused by placentapraevia4-17 What is placenta praevia?Placenta praevia means that the placenta is implanted either wholly orpartially in the lower segment of the uterus. The placenta may extend downto, or cover the internal os of the cervix. When the lower segment starts toform or the cervix begins to dilate, the placenta becomes partially separatedand this causes maternal bleeding.

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4-18 Which patients have the highest risk of placenta praevia?1. With regard to their previous obstetric history, patients who:◦ Are grande multiparas, i.e. who are para 5 or higher.◦ Have had a previous caesarean section.

2. With regard to their present obstetric history, patients who:◦ Have a multiple pregnancy.◦ Have had a threatened abortion, especially in the second trimester.◦ Have an abnormal presentation.

4-19 What in the history of the bleeding suggests the diagnosis ofplacenta praevia?

1. The bleeding is painless and bright red in colour.2. Fetal movements are still present after the bleed.

4-20 What are the typical findings on physical examination in apatient with placenta praevia?

1. General examination may show signs that the patient is shocked, and theamount of bleeding corresponds to the degree of shock. The patient’shaemoglobin concentration may be normal if done at the time of thehaemorrhage or low depending on the amount of blood loss and the timeinterval between the haemorrage and the haemoglobin measurement.However, the fisrt bleed is usually not severe.

2. Examination of the abdomen shows that:

◦ The uterus is soft and not tender to palpation.◦ The uterus is not bigger than it should be for the patient’s dates.◦ The fetal parts can be easily palpated, and the fetal heart is present.◦ There may be an abnormal presentation. Breech presentation or oblique or

transverse lies are commonly present.◦ In cephalic presentations, the head is not engaged and is easily balottable

above the pelvis.

The diagnosis of placenta praevia can usually be made from thehistory and physical examination.

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4-21 Do you think that engagement of the head can occur if there isa placenta praevia present?No. If there is 2/5 or less of the fetal head palpable above the pelvic brim onabdominal examination, then placenta praevia can be excluded and a digitalvaginal examination can be done safely. The first vaginal examination mustalways be done carefully.

Two fifths or less of the fetal head palpable above the pelvicbrim excludes the possibility of placenta praevia.

4-22 What do you understand by a ‘warning bleed’?This is the first bleeding that occurs from a placenta praevia, when the lowersegment begins to form at about 34 weeks, or even earlier.

4-23 Are there any investigations that can confirm the diagnosis ofplacenta praevia?An ultrasound examination must be done in order to localise the placenta, ifthe patient is not bleeding actively.

4-24 What action should you take if a routine ultrasoundexamination early in pregnancy shows a placenta praevia?In most cases, the position of the placenta moves away from the internal os ofthe cervix as pregnancy continues. A follow-up ultrasound examination mustbe arranged at a gestational age of 32 weeks.

4-25 What is the further management after making the diagnosis ofplacenta praevia?Refer the patient to a hospital where she will be admitted and managedconservatively until 36 to 38 weeks depending on the severity of the bleed oruntil active bleeding starts.

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4-26 When you refer a patient, what precautions should you take toensure the safety of the patient in transit?

1. A shocked patient should have 2 intravenous infusion lines with Balsol orRinger’s lactate running in fast. A doctor should accompany the patient ifpossible. If not possible, a registered nurse or trained person from theambulance service should accompany her.

2. A patient who is no longer bleeding, should also have an intravenousinfusion, and be accompanied by a registered nurse or a trained person fromthe ambulance service.

4-27 When would you suspect an antepartum haemorrhage ofunknown cause?In patients who have all the following factors:

1. Mild antepartum haemorrhage when there are no signs of shock and the fetalcondition is good.

2. When the history and examination do not suggest a severe abruptioplacentae.

3. When local causes of bleeding have been excluded on a speculumexamination.

4. When placenta praevia has been excluded by an ultrasound examination.

A blood-stained vaginal discharge4-28 How does a patient describe a blood-stained vaginaldischarge?As a vaginal discharge mixed with a small amount of blood.

4-29 How does a patient describe a ‘show’?As a slight vaginal bleed consisting of blood mixed with mucus.

A BLOOD-STAINED VAGINAL DISCHARGE 145

4-30 How should you manage a patient with a history of a blood-stained vaginal discharge or a ‘show’?

1. After getting a good history and ensuring that the condition of the fetus issatisfactory, a careful speculum examination should be done.

2. The speculum is only inserted for 5 cm, carefully opened, and then introducedfurther until the cervix can be seen.

3. Any bleeding through a closed cervical os indicates an antepartumhaemorrhage.

4. A ‘show’ is the most likely cause, if the cervix is a few centimetres dilated,with bulging membranes, or if the presenting part of the fetus is visible.

5. A vaginitis is the most likely cause, if a blood-stained discharge is seen in thevagina.

4-31 How should you treat a blood-stained discharge due tovaginitis in pregnancy?

1. Organisms identified on the cervical cytology smear are the most likely causeof the vaginitis.

2. If no organisms are identified on the cytology smear, or a smear was notdone, then Trichomonas vaginalis is most probably present.

To treat a Trichomonal vaginitis, both the patient and her partner shouldreceive a single dose of 2 g metronidazole (Flagyl) orally.

4-32 Should metronidazole be used during pregnancy?Metronidazole should not be used in the first trimester of pregnancy, unless itis absolutely necessary, as it may cause congenital abnormalities in the fetus.The patient and her partner must be warned that metronidazole causes severenausea and vomiting if it is taken with alcohol. The risk of congenitalabnormalities caused by alcohol may also be increased by metronidazole.

4-33 How do you manage a patient with contact bleeding?Contact bleeding occurs if the cervix is touched (e.g. during sexualintercourse or during a vaginal examination).

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1. When there is normal cervical cytology (Papanicolaou smear), the contactbleeding is probably due to a cervicitis. If it is troublesome, the patient shouldbe given a course of oral erythromycin 500 mg 6 hourly for 7 days.

2. With abnormal cervical cytology, the patient should be correctly managed.Cervical intra-epithelial neoplasia causes contact bleeding.

4-34 What action should you take when the bleeding is from acervical ulcer or tumour?The patient most probably has an infiltrating cervical carcinoma and shouldbe correctly managed.

Case study 1A patient, who is 35 weeks pregnant, presents with a history of vaginalbleeding.

1. Why does this patient need to be assessed urgently?Because an antepartum haemorrhage should always be regarded as anemergency, until a cause for the bleeding is found. Thereafter, the correctmanagement can be given.

2. What is the first step in the management of a patient with anantepartum haemorrhage?The clinical condition of the patient must be assessed. Special attention mustbe paid to signs of shock.

3. What must be done if the patient has a rapid pulse rate and signsof shock?Put up two intravenous infusions (‘drips’) with Balsol or Ringer’s lactate, torun in quickly in order to actively resuscitate the patient. Insert a Foley’scatheter into the patient’s bladder, to measure the urinary volume and tomonitor further urine output. If blood is available, take blood for cross-matching at the time of putting up the intravenous infusion and order 2 ormore units of blood urgently.

CASE STUDY 1 147

4. What is the next step in the management of a patient with anantepartum haemorrhage?The patient needs to be referred to hospital.

Case study 2A patient who is 32 weeks pregnant, according to her antenatal card, presentswith a history of severe vaginal bleeding and abdominal pain. The bloodcontains dark clots. Since the haemorrhage, the patient has not felt her fetusmove. The patient’s blood pressure is 80/60 mmHg and the pulse rate 120beats per minute.

1. What is your clinical diagnosis?The history is typical of an abruptio placentae and most likely she has anintra-uterine death.

2. If the clinical examination confirms the diagnosis, what shouldbe the first step in the management of this patient?The patient’s blood pressure and pulse rate indicate that she is shocked.Therefore, she must first be resuscitated.

3. What is the next step in the management of the patient, thatrequires urgent attention?The patient must then be referred to hospital.

4. What precautions should you take to ensure the safety of thepatient in transit?A shocked patient should have 2 intravenous infusion lines with Balsol orRinger’s lactate running in fast. A doctor should accompany the patient ifpossible. If not possible, a registered nurse should accompany her. A patientwho is no longer bleeding, should also have an intravenous infusion, and beaccompanied by a registered nurse or a trained person from the ambulanceservice, whenever possible.

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Case study 3A patient is seen at the antenatal clinic at 35 weeks gestation with a breechpresentation. The patient is referred to see the doctor the following week, foran external cephalic version. That evening she has a painless, bright redvaginal bleed.

1. What is your diagnosis?The history and the presence of an abnormal lie suggest that the bleeding isthe result of a placenta praevia.

2. Why is the history typical of a placenta praevia?The bleeding is painless and bright red. She also has an abnormal lie.

3. What do expect to find in addition to a breech presentation onabdominal examination?The uterus will be soft, with no tenderness and the size will be appropriatefor her gestational age. The presenting part will be high.

4. What should be the initial management of the patient?The condition of the mother should first be assessed and the patientresuscitated, if necessary. The patient must then be referred to hospital.

Case study 4A patient books for antenatal care at 30 weeks gestation. When you informher of the danger signs during pregnancy, she says that she has had a vaginaldischarge for the past 2 weeks. At times the discharge has been blood stained.

1. Has this patient had a antepartum haemorrhage?The history suggests a blood-stained vaginal discharge rather than anantepartum haemorrhage.

CASE STUDY 4 149

2. What is the most probable cause of the blood-stained vaginaldischarge?A vaginitis. This can usually be confirmed by a speculum examination.

3. What is the most likely cause of a vaginitis with a blood-staineddischarge?Trichomonas vaginalis. Therefore, if no organisms were identified on thecervical cytology smear or a smear was not done, Trichomonas vaginalis ispresumed to be the cause of the vaginitis.

4. How should you treat a patient with Trichomonal vaginitis?A single dose of 2 g metronidazole (Flagyl) is given orally to both the patientand her partner. Both must be warned against drinking alcohol for a few daysafter taking metronidazole.

150 ANTEPARTUM HAEMORRHAGE

Figure 4-1: Flow diagram: Initial management of a patient with vaginal bleeding

CASE STUDY 4 151

5Preterm labour andpreterm rupture of themembranesBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Define preterm labour and preterm rupture of the membranes.• Understand why these conditions are very important.• Understand the role of infection in causing preterm labour and preterm

rupture of the membranes.• List which patients are at increased risk of these conditions and what

preventive measures should be taken.• Diagnose preterm labour and preterm rupture of the membranes.• Initiate the correct management and appropriate referral of patients.

Preterm labour and preterm rupture of themembranes5-1 What is preterm labour?Preterm labour is diagnosed when there are regular uterine contractionsbefore 37 weeks of pregnancy, together with either of the following:

152 PRETERM LABOUR AND PRETERM RUPTURE OF THE MEMBRANES

1. Cervical effacement and/or dilatation.2. Rupture of the membranes.

5-2 What is preterm rupture of the membranes?Preterm rupture of the membranes is diagnosed when the membranesrupture before 37 weeks, in the absence of uterine contractions.

5-3 What is prelabour rupture of the membranes?Prelabour rupture of the membranes is defined as rupture of themembranes for at least one hour before the onset of labour in a termpregnancy.

5-4 How should you diagnose preterm labour if the gestational ageis unknown?Preterm labour is diagnosed if the estimated fetal weight is below 2500 g. Thesymphysis-fundus height will be less than 35 cm.

5-5 Why are preterm labour and preterm rupture of the membranesimportant?Preterm labour and preterm rupture of the membranes are major causes ofperinatal death because:

1. Preterm delivery, especially before 34 weeks, commonly results in the birth ofan infant who develops hyaline membrane disease and other complications ofprematurity.

2. Preterm labour and preterm rupture of the membranes are often accompaniedby bacterial infection of the membranes and placenta, that may causecomplications for both the mother and the fetus. The mother and fetus maydevelop severe infection, which is life threatening.

5-6 What is the commonest known cause of preterm labour andpreterm rupture of the membranes?In many cases the cause is unknown, but increasing evidence points toinfection of the membranes and placenta as the commonest known cause ofboth preterm labour and preterm rupture of the membranes.

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Infection of the membranes and placenta is the commonestrecognised cause of preterm labour and preterm rupture of themembranes.

5-7 What is infection of the membranes and placenta?Infection of the membranes and placenta causes an acute inflammation of theplacenta, membranes and decidua. This condition is called chorioamnionitis.It may occur with intact or ruptured membranes.

Bacteria from the cervix and vagina spread through the endocervical canal toinfect the membranes and placenta. Later these bacteria may colonise theliquor, from where they may infect the fetus.

Infection of the membranes and placenta (chorioamnionitis)may occur with either intact or ruptured membranes.

5-8 What is the clinical presentation of chorioamnionitis?Usually chorioamnionitis is asymptomatic (subclinical chorioamnionitis) and,therefore, the clinical diagnosis is often not made. However, the followingsigns may be present:

1. Fetal tachycardia.2. Maternal pyrexia and/or tachycardia.3. Tenderness of the uterus.4. Drainage of offensive liquor, if the membranes have ruptured.

If any of the above signs are present, a diagnosis of clinicalchorioamnionitis must be made.

5-9 What factors may predispose to chorioamnionitis?1. Rupture of the membranes.2. Exposure of the membranes due to dilatation of the cervix.3. Coitus during the second half of pregnancy.

However, in many cases, the factors that result in chorioamnionitis are notknown.

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5-10 Can chorioamnionitis cause complications during thepuerperium?Yes, it can cause serious problems.

1. Bacteria that have colonised the amniotic fluid, may infect the fetus and theinfant may present with signs of infection (congenital pneumonia orsepticaemia) at or soon after birth.

2. Chorioamnionitis may cause infection of the genital tract (puerperal sepsis)which, if not treated correctly, may result in septicaemia, the need forhysterectomy, and possibly in maternal death. These complications canusually be prevented by starting a course of broad-spectrum antibiotics (e.g.intravenous ampicillin plus metronidazole), as soon as the diagnosis ofclinical chorioamnionitis is made.

5-11 What factors other than chorioamnionitis can lead to pretermlabour and preterm rupture of the membranes?The following maternal, fetal and placental factors may be associated withpreterm labour and/or preterm rupture of the membranes:

1. Maternal factors:◦ Pyrexia, as the result of an acute infection other than chorioamnionitis, e.g.

acute pyelonephritis or malaria.◦ Uterine abnormalities, such as congenital uterine malformations (e.g. septate

or bicornuate uterus) and uterine myomas (fibroids).◦ Incompetence of the internal cervical os (‘cervical incompetence’).

2. Fetal factors:◦ A multiple pregnancy.◦ Polyhydramnios◦ Congenital malformations of the fetus.◦ Syphilis.

3. Placental factors:◦ Placenta praevia.◦ Abruptio placentae.

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5-12 Which patients are at an increased risk of preterm labour orpreterm rupture of the membranes?Both preterm labour and preterm rupture of membranes are more common inpatients who:

1. Have a past history of preterm labour.2. Have no antenatal care.3. Live in poor socio-economic circumstances.4. Smoke, use alcohol or abuse habit-forming drugs.5. Are underweight due to undernutrition.6. Have coitus in the 2nd half of pregnancy, when they are at an increased risk

of preterm labour or infections.7. Have any of the maternal, fetal or placental factors listed above.

The most important risk factor for preterm labour is a previoushistory of preterm delivery.

5-13 What can be done to decrease the incidence of thesecomplications?

1. Take measures to ensure that all pregnant women receive antenatal care.2. Identify patients with a past history of preterm labour.3. Give advice about the dangers of smoking, alcohol and the use of habit-

forming drugs.4. Advise against coitus during the late 2nd and in the 3rd trimester in

pregnancies at high risk for preterm labour or preterm rupture of themembranes. If coitus occurs during pregnancy in these patients, the use ofcondoms must be recommended as this may reduce the risk ofchorioamnionitis.

5. Insert a McDonald suture at 14–16 weeks, in patients with a provenincompetent internal cervical os.

6. Prevent teenage pregnancies.7. Improve the socio-economic and nutritional status of poor communities.8. Arrange that the workload of women, who have to do heavy manual labour,

is decreased when they are pregnant and that an opportunity to rest duringworking hours is allowed.

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5-14 How should you manage a patient at increased risk of pretermlabour or preterm rupture of the membranes?

1. Patients at increased risk must have 2 weekly vaginal examinations from 24weeks, in order to make an early diagnosis of preterm cervical effacementand/or dilatation.

2. In all women with cervical effacement or dilatation before 34 weeks, thefollowing preventive measures can then be taken:

◦ Bed rest. This can be at home, except when the home circumstances are poor,in which case the patient should be referred to the hospital for admission.

◦ Sick leave must be arranged for working patients.◦ Coitus must be forbidden.◦ Advice must be given to report immediately, if contractions or rupture of the

membranes occur.◦ Women with preterm labour or preterm rupture of the membranes must be

seen as soon as possible, and the correct measures taken to prevent thedelivery of a severely preterm infant.

All patients should be told to immediately report pretermlabour or preterm rupture of the membranes.

5-15 What should you do if a patient threatens to deliver a preterminfant?

1. Infants born between 34 and 36 weeks can usually be cared for in a level 1hospital.

2. However, women who threaten to deliver between 28 and 33 weeks, shouldbe referred to a level 2 or 3 hospital with a neonatal intensive care unit.

3. If the birth of a preterm baby cannot be prevented, it must be rememberedthat the best incubator for transporting an infant is the mother’s uterus. Evenif the delivery is inevitable, an attempt to suppress labour should be made, sothat the patient can be transferred before the infant is born.

4. The better the condition of the infant on arrival at the neonatal intensive careunit, the better is the prognosis.

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Diagnosis of preterm labour and pretermrupture of the membranes5-16 How should you distinguish between Braxton Hickscontractions and the contractions of preterm labour?Braxton Hicks contractions:

1. Are irregular.2. May cause discomfort but are not painful.3. Do not increase in duration or frequency.4. Do not cause cervical effacement or dilatation.

The duration of contractions cannot be used as Braxton Hicks contractionsmay last up to 60 seconds.

In contrast, the contractions of preterm or early labour:

1. Are regular, at least one per 10 minutes.2. Are painful.3. Increase in frequency and duration.4. Cause effacement and dilatation of the cervix.

5-17 How should you confirm the diagnosis of preterm labour?Both of the following will be present in a patient of less than 37 weeksgestation:

1. Regular uterine contractions, palpable on abdominal examination, of at leastone per 10 minutes.

2. A history of rupture of the membranes, or cervical effacement and/ordilatation on vaginal examination.

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5-18 How can you diagnose preterm rupture of the membranes?1. A patient of less than 37 weeks gestation will give a history of sudden

drainage of liquor followed by a continual leak of smaller amounts, withoutassociated uterine contractions.

2. A sterile speculum examination will confirm the diagnosis of rupturedmembranes.

3. A digital vaginal examination must not be done as it is of little value indiagnosing rupture of the membranes and may increase the risk of infection.

A digital vaginal examination must not be done in pretermrupture of the membranes.

5-19 What is the value of a sterile speculum examination whenpreterm rupture of the membranes is suspected?

1. The danger of ascending infection is not increased by this procedure.2. Observing drainage of liquor from the cervical os confirms the diagnosis of

ruptured membranes.3. If no drainage of liquor is observed, drainage can sometimes be seen if the

patient is asked to cough.4. If no drainage of liquor is seen, a smear should be taken from the posterior

vaginal fornix with a wooden spatula to determine the pH.5. The possibility of cord prolapse can be excluded or confirmed.6. It is also important to see whether the cervix is long and closed, or whether

there is already clear evidence of cervical effacement and/or dilatation.7. A patient with a profuse vaginal discharge or stress incontinence (leaking

urine when coughing or laughing) may think that she is draining liquor. Aspeculum examination will help to confirm or rule out this possibility.

5-20 How should you test the vaginal pH?1. The pH of the vagina is acid but the pH of liquor is alkaline.2. Red litmus paper is pressed against the moist spatula. If the red litmus

changes to blue, then liquor is present in the vagina, indicating that themembranes have ruptured. If blue litmus is used, it will remain blue withrupture of membranes or change to red if the membranes are intact.

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5-21 How should you manage patients with preterm labour,preterm rupture of membranes and prelabour rupture ofmembranes?

1. If the gestational age is less than 36 weeks, these patients should be referredto a level I hospital for admission. If the gestational age is less than 34 weeks,she must be referred to a level 2 hospital.

2. If the gestational age is 36 weeks of more, patients can safely be delivered in amidwife obstetric unit (MOU) or district hospital. At a gestational age of 36weeks babies will not develop the complications of preterm infants and couldbe discharged 6 hours following delivery with their mothers.

5-22 How will you decide that a patient is less than 36 weekspregnant if the duration of the pregnancy is unknown?This is done by measuring the symphysis-fundus height and by doing acomplete abdominal examination. An estimated fetal weight of less than 2500g, suggests a gestational age of less than 36 weeks. The symphysis-fundusheight measurement will be less than 34 cm.

5-23 What should be done if preterm labour has been diagnosedand the patient is less than 34 weeks pregnant?Contractions should be suppressed with nifedipine (Adalat). The patient mustthen be transferred as an urgent transferal to a level 2 hospital. If nifedipine isnot available salbutamol (Ventolin) can be used. This measure will:

1. Improve the chance of successful suppression of preterm labour at thehospital.

2. Reduce the risk of a delivery before arrival at the hospital or clinic.

Infants born before 34 weeks are at increased risk of developingcomplications. Therefore, suppression of contractions to allow continuationof pregnancy is important in these cases. The earlier the suppression ofcontractions is started the better the chance of successful suppression will be.

5-24 How would you decide that a patient is less than 34 weekspregnant if the duration of the pregnancy is uknown?This is done by measuring the symphysis-fundus height and by doing acomplete abdominal examination.

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Labour must be suppressed if the estimated fetal weight is less than 2000 g asthis suggests an estimated gestational age of less than 34 weeks. Thesymphysis-fundus height measurement will be less than 33 cm.

5-25 How should you give nifedipine for the suppression of pretermlabour?Three nifedipine (Adalat) 10 mg capsules (total 30 mg) should be taken bymouth. If there are still contractions with cervical dilatation and effacement 3hours after the initial dose, a follow-up dose of 20 mg must be given.

5-26 What are the contraindications to the use of nifedipine insuppressing labour?Nifedipine (Adalat) cannot be used for the suppression of preterm labour ifpatients have hypertension, e.g. suffering from any of the hypertensivedisorders of pregnancy.

5-27 How should you use salmutamol for the suppression ofpreterm labour?

1. A half an ampoule (0.5 ml = 250 μg) of salbutamol (Ventolin) is diluted with9.5 ml of sterile water in a 10 ml syringe and administered slowlyintravenously (0.5 ml per minute) while the maternal heart rate is carefullymonitored for a tachycardia.

2. The patient must be warned that salbutamol causes tachycardia (palpitations).

5-28 What are the contraindications to the use of salmotamol insuppressing labour?

1. Heart valve disease. The use of salmutamol (or another beta2 stimulant), canendanger the patient’s life, especially if she has a narrowed heart valve, e.g.mitral stenosis.

2. A shocked patient.3. A patient with a tachycardia, e.g. as the result of an acute infection.

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5-29 What advice should you give to a woman who has delivered apreterm infant?

1. She should be seen at a level 2 hospital before her next pregnancy to beassessed for possible causes, e.g. cervical incompetence.

2. She must book early in any future pregnancy.

Case study 1A patient, 32 weeks pregnant, presents with regular painful uterinecontractions. She is apyrexial and appears clinically well. On vaginalexamination, the cervix is 4 cm dilated. The fetal heart rate is 138 beats perminute with no decelerations.

1. Is the patient in true or false labour? Give the reasons for yourdiagnosis.She is in true labour because she is getting regular painful contractions andher cervix is 4 cm dilated.

2. What signs exclude a diagnosis of clinical chorioamnionitis?The patient is apyrexial, clinically well and has a normal fetal heart rate.

3. Why could chorioamnionitis still be the cause of her pretermlabour?Because chorioamnionitis is often asymptomatic (subclinical chorio-amnionitis).

4. Would you allow labour to continue or would you suppresslabour prior to referring the patient to the hospital?Labour should be suppressed because the pregnancy is of less than 34 weeksduration.

162 PRETERM LABOUR AND PRETERM RUPTURE OF THE MEMBRANES

5. How should labour be suppressed?Labour must be suppressed using nifedipine (Adalat) or salbutamol(Ventolin).

Case study 2A patient, who is 36 weeks pregnant, reports that she has been drainingliquor since earlier that day. The patient appears well, with normalobservations, no uterine contractions and the fetal heart rate is normal.

1. Would you diagnose rupture of the membranes on the historygiven by the patient?No, other causes of fluid draining from the vagina may cause confusion, e.g. avaginitis or stress incontinence.

2. How would you confirm rupture of the membranes?A sterile speculum examination should be done. If there is no clear evidenceof liquor draining, the vaginal pH must be determined with Litmus paper toidentify liquor.

3. Why should you not perform a digital vaginal examination toassess whether the cervix is dilated or effaced?A digital vaginal examination is contra-indicated in the presence of ruptureof the membranes if the patient is not already in labour, because of the risk ofintroducing infection.

4. Is this patient at high risk of having or developingchorioamnionitis?Yes. The preterm prelabour rupture of the membranes may have been causedby chorioamnionitis. In addition, all patients with ruptured membranes are atan increased risk of developing chorioamnionitis.

CASE STUDY 2 163

5. Should the patient be referred to a level I (district hospital/MOU)or level II hospital? Give your reasons.She is 36 weeks pregnant and there are no signs of chorio-amnionitis. Sheshould be referred to a level I hospital or MOU.

Case study 3An unbooked patient presents at a primary care clinic with a 5 day history ofruptured membranes. She is pyrexial with lower abdominal tenderness and isdraining offensive liquor. She is uncertain of her dates but abdominalexamination suggests that she is at term. Treatment has been started withoral ampicillin.

1. What signs of clinical chorioamnionitis does the patient have?She is pyrexial, with lower abdominal tenderness and she has offensive liquor.

2. How should the patient be managed?There is danger of spreading infection in both the mother and fetus if theinfant is not delivered. The patient must be referred to the next level of careas an urgent case.

3. Is oral ampicillin the correct initial treatment while waiting forthe transfer? Give your reasons.Chorioamnionitis may result in a severe infection of the genital tract thatmay cause a maternal death. These complications can usually be prevented bystarting broad-spectrum antibiotics (ampicillin and metronidazole) as early aspossible. The ampicillin must be given intravenously.

4. Why is the infant at increased risk for neonatal complications?The chorioamnionitis has already spread to the liquor as this is offensive.Therefore, the fetus may also be infected and may present with congenitalpneumonia or septicaemia at birth.

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6The puerperium andfamily planningBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Define the puerperium and list the physical changes which occur during thepuerperium.

• Manage the normal puerperium.• Assess a patient at the 6 week postnatal visit.• Diagnose and manage the various causes of puerperal pyrexia.• Recognise the puerperal psychiatric disorders.• Diagnose and manage secondary postpartum haemorrhage.• Teach the patient the concept of ‘the mother as a monitor’.• Explain the wider meaning of family planning and give contraceptive

counselling.• List the health benefits, efficiency, contraindications and side effects of the

various contraceptive methods.• Advise a postpartum patient on the most appropriate method of

contraception.

OBJECTIVES 165

The puerperium6-1 What is the puerperium?The puerperium is the period from the end of the third stage of labour untilmost of the patient’s organs have returned to their pre-pregnant state.

6-2 How long does the puerperium last?The puerperium starts when the placenta is completely delivered and lasts for6 weeks. However, some organs may only return to their pre-pregnant stateweeks or even months after the 6 weeks have elapsed (e.g. the ureters). Otherorgans never regain their pre-pregnant state (e.g. the perineum).

It is important for the midwife or doctor to assess whether the patient hasreturned, as closely as possible, to normal health and activity by the end ofthe puerperium.

The puerperium starts when the placenta is delivered and lastsfor 6 weeks.

6-3 Why is the puerperium important?1. The patient recovers from her labour, which often leaves her tired and even

exhausted. There is, nevertheless, a feeling of great relief and happiness2. The patient undergoes what is probably the most important psychological

experience of her life, as she realises that she is responsible for anotherhuman being, her infant.

3. Breastfeeding should be established.4. The patient should decide, with the guidance of a midwife or doctor, on an

appropriate contraceptive method.

6-4 What physical changes occur in the puerperium?Almost every organ undergoes change in the puerperium. These adjustmentsrange from mild to marked. Only those changes which are important in themanagement of the normal puerperium following discharge from the hospitalor clinic (midwife obstetric unit–MOU) will be described here.

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1. Skin.◦ The increased pigmentation of the face, abdominal wall and vulva lightens

but the areolae may remain darker than they were before pregnancy.◦ With the onset of diuresis (increased amount of urine passed) the general

puffiness and any oedema disappear in a few days.◦ Marked sweating may occur for some days.

2. Abdominal wall.◦ The abdominal wall is flaccid (loose and wrinkled) and some separation

(divarication) of the abdominal muscles occurs.◦ Pregnancy marks (striae gravidarum), where present, do not disappear but do

tend to become less red in time.

3. Gastrointestinal tract.◦ Thirst is common.◦ The appetite varies from anorexia to ravenous hunger.◦ There may be flatulence (excess wind).◦ Many patients are constipated as a result of decreased tone of the bowel

during pregnancy and, decreased food intake during labour. They may alsohave passed stool during labour and delivery. Constipation is common in thepresence of an episiotomy or painful haemorrhoids. Giving a patient anenema on admission in labour is of no advantage to her and contributes toconstipation in the puerperium.

4. Urinary tract.◦ Retention of urine is common and may result from decreased tone of the

bladder in pregnancy and oedema of the urethra following delivery. Dysuria(discomfort or pain) and difficulty in passing urine may lead to completeurinary retention or retention with overflow incontinence. A full bladder willinterfere with uterine contraction.

◦ A diuresis usually occurs on the second or third day of the puerperium. Inoedematous patients it may start immediately after delivery.

◦ Stress incontinence (a leak of urine) is common when the patient laughs orcoughs. It may first be noted during the puerperium or follow stressincontinence which was present during pregnancy. Often stress incontinencebecomes worse initially but tends to improve with time and with pelvic floorexercises.

Pelvic floor exercises are also known as pinch or ‘knyp’ exercises. Themuscles that are exercised are those used to suddenly stop a stream of urine

THE PUERPERIUM 167

midway through micturition. These muscles should be tightened, as stronglyas possible, 10 times in succession on at least 4 occasions a day.

5. Blood.◦ The haemoglobin concentration becomes stable around the 4th day of the

puerperium.◦ The platelet count is raised and the platelets become more sticky from the 4th

to 10th day after delivery. These and other changes in the clotting(coagulation) factors may cause thrombo-embolism in the puerperium.

6. Breasts. Marked changes occur during the puerperium with the productionof milk

7. Genital tract. Very marked changes occur in the genital tract during thepuerperium:

◦ Vulva: The vulva is swollen and congested after delivery, but these featuresrapidly disappear. Tears and/or an episiotomy usually heal easily.

◦ Vagina: Immediately after delivery the vagina is large, smooth walled,oedematous and congested. It rapidly shrinks in size and rugae return by thethird week. The vaginal walls remain laxer than before and some degree ofvaginal prolapse (cystocoele and/or rectocoele) is common after a vaginaldelivery. Small vaginal tears, which are very common, usually heal in 7 to 10days.

◦ Cervix: After the first vaginal delivery the circular external os of thenullipara becomes slit like. For the first few days after delivery the cervixremains partially open, admitting 1 or 2 fingers. By the 7th day postpartumthe cervical os will have closed so that a finger can no longer be passedthrough it.

◦ Uterus: The most important change occurring in the uterus is involution.After delivery the uterus is about the size of a 20 week pregnancy. By the endof the first week it is about 12 weeks in size. At 14 days the fundus of theuterus should no longer be palpable above the symphysis pubis. After 6weeks it has decreased to the size of a normal multiparous uterus, which isslightly larger than a nulliparous one. This remarkable decrease in size is theresult of contraction and retraction of the uterine muscle. The normallyinvoluting uterus should be firm and non-tender. The decidua of the uterusnecroses (dies), due to ischaemia, and is shed as the lochia. The averageduration of red lochia is 24 days. Thereafter, the lochia becomes straw

168 THE PUERPERIUM AND FAMILY PLANNING

coloured. Normal lochia has a typical, non-offensive smell. Offensive lochia isalways abnormal.

Management of the puerperiumThe management of the puerperium may be divided into 3 stages:

1. The management of the first hour after delivery of the placenta (sometimescalled the fourth stage of labour).

2. The management of the rest of the puerperium.3. The 6 week postnatal visit.

6-5 When should a postpartum patient be allowed to go home?This will depend on:

1. Whether the patient had a normal pregnancy and delivery.2. The circumstances of the hospital or clinic where the patient was delivered.

6-6 When should a patient be allowed to go home following anormal pregnancy and delivery?A patient who has had a normal pregnancy and delivery may be allowed togo home about 6 hours after the birth of her infant, provided:

1. The observations done on the mother and infant since delivery have beennormal.

2. The mother and infant are normal on examination, and the infant is suckingwell.

3. The patient is able to attend her nearest clinic on the day after delivery (day1) and then again on days 3 and 5 after delivery for postnatal care, or bevisited at home by a midwife on those days. Primigravidas should be seenagain on day 7, especially to ensure that breastfeeding is well established.

A patient should only be discharged home after delivery if no abnormalitiesare found when the following examinations are performed:

• A general examination, paying particular attention to the:◦ Pulse rate.◦ Blood pressure.

MANAGEMENT OF THE PUERPERIUM 169

◦ Temperature.◦ Haemoglobin concentration.

• An abdominal examination, paying particular attention to the state ofcontraction and/or tenderness of the uterus.

• An inspection of the episiotomy site and the amount, colour and odour of thelochia.

• Patients who received no antenatal care and delivered without having anyscreening tests, must have a rapid syphilis test and a rapid test for Rhesusgrouping. Counselling for HIV testing must also be done.

It is important to arrange for suitable contraception before the patient isdischarged home.

The Essential Postnatal Obstetric Care (EPOC) card with the mother’s andinfant’s discharge information could now be completed. If any of the shadedblocks are ticked, treatment is required or the mother needs to be referred tothe next level of care. The checklist will again be used during the day-5 or -6visit to check that all the important tasks have been completed (i.e. as aquality control tool).

6-7 When should a patient be discharged from hospital following acomplicated pregnancy and delivery?This will depend on the nature of the complication and the method ofdelivery. For example:

1. A patient with pre-eclampsia should be kept in hospital until her bloodpressure has returned to normal or is well controlled with oral drugs.

2. A patient who has had a caesarean section will usually stay in hospital for 2days or longer.

3. A patient who has had a postpartum haemorrhage must be kept in hospitalfor at least 24 hours to ensure that her uterus is well contracted and thatthere is no further bleeding.

4. HIV-positive patients are at increased risk for infections. Careful examinationfor any signs of infection is required and the patients should be kept inhospital or the delivery clinic for 24 hours.

170 THE PUERPERIUM AND FAMILY PLANNING

6-8 How will the circumstances at a clinic or hospital influence thetime of discharge?

1. Some clinics have no space to accommodate patients for longer than 6 hoursafter delivery. Therefore, patients who cannot be discharged safely at 6 hourswill have to be transferred to a hospital.

2. Some hospitals manage patients who live in remote areas where follow-up isnot possible. These patients will have to be kept in hospital longer beforedischarge.

6-9 What postnatal care should be given during the puerperiumafter the patient has left the hospital or clinic?Ideally, visits for postnatal care must be scheduled for the day followingdischarge (day 1), day 3 and day 5 or 6. Limited health care facilities or longdistances may require the visits to be limited to a single visit on day 5 or 6.

The following observations must be done on the mother:

1. Assess the patient’s general condition.2. Ask about problems with breathing and coughing.3. Observe the pulse rate, blood pressure and temperature.4. Determine the height of the uterine fundus and assess whether any uterine

tenderness is present.5. Assess whether the amount of vaginal bleeding is more than normal.6. Assess the amount, colour and odour of the lochia.7. Check whether the episiotomy is healing satisfactorily.8. Ask if the patient passes urine normally and enquire about any urinary

symptoms. Reassure the patient if she has not passed a stool by day 5.9. Measure the haemoglobin concentration if the patient appears pale.

10. Assess the condition of the patient’s breasts and nipples. Determine whethersuccessful breastfeeding has been established.

The following observations must be done on the infant:

1. Assess whether the infant is feeding well and is satisfied after a feed.2. Assess whether the infant appears well and is thriving.3. Check whether the infant is jaundiced.4. Examine the umbilical stump for signs of infection.5. Examine the eyes for conjunctivitis.6. Ask whether the infant has passed urine and stool.

MANAGEMENT OF THE PUERPERIUM 171

The successful establishment of breastfeeding is one of themost important goals of patient care during the puerperium.

The EPOC card for the day 5 to 6 visit could now be completed. The checklistwill again be used during the 6 weeks visit.

6-10 How can you help to establish successful breastfeeding?By providing patient education and motivation. This should preferably startbefore pregnancy and continue throughout the antenatal period and afterdelivery. Encouragement and support are very important during the firstweeks after delivery. The important role of successful breastfeeding inlowering infant mortality in poor communities must be remembered.

6-11 Which topics should you include under patient education inthe puerperium?Patient education regarding herself, her infant and her family should not startduring the puerperium, but should be part of any woman’s general education,starting at school. Topics which should be emphasised in patient education inthe puerperium include:

1. Personal and infant care.2. Offensive lochia, fever or severe abdominal pain must be reported

immediately.3. The ‘puerperal blues’.4. Family planning and safer sex.5. Any special arrangements for the next pregnancy and delivery.6. When to start coitus again. Usually coitus can be started 3 to 4 weeks

postpartum when the episiotomy or tears have healed.

Patient education is an important and often neglected part ofpostnatal care.

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6-12 When should a patient be seen again after postnatal care hasbeen completed?The postnatal visit is usually held 6 weeks after delivery. By this time almostall the organ changes which occurred during pregnancy should havedisappeared.

The six week postnatal visit6-13 Which patients need to attend a 6 week postnatal clinic?Patients with specific problems that need to be followed up 6 weekspostpartum, e.g. patients who were discharged with hypertension need tocome back to have their blood pressure measured. Patients who are healthymay be referred directly to the mother and child health clinics for follow upand need not attend a special 6 week postnatal clinic.

6-14 What are the objectives of the 6-week postnatal visit?It is important to identify the reason why the patient was asked to attend theclinic and to determine whether:

1. The patient is healthy and has returned to her normal activities.2. The infant is well and growing normally.3. Breastfeeding has been satisfactorily established.4. Contraception has been arranged to the patient’s satisfaction.5. The patient has been referred to a maternal and child health clinic for further

care.6. The patient has any questions about herself, her infant or her family.

6-15 How should the 6 week postnatal visit be conducted?1. The patient is asked how she and her infant have been since the last postnatal

care visit.2. The patient is then examined. On examination pay particular attention to the

blood pressure and breasts, and look for signs of anaemia. An abdominalexamination is followed by a speculum examination to check whether theepisiotomy, vulval or vaginal tears have healed.

THE SIX WEEK POSTNATAL VISIT 173

3. A cytology smear of the cervix should be taken if the patient is 30 years orolder and has not previously had a normal cervical smear. A cervical smearshould also be taken on any woman who has previously had an abnormalsmear.

4. The haemoglobin is measured and the urine tested for glucose and protein.5. Attention must be given to any specific reason why the patient is being

followed up, e.g. arrangements for the management of patients who remainhypertensive after delivery.

6. The patient is given health education. It should again be remembered to askher whether she has any questions she would like to ask.

If the patient and her infant are both well, they are referred to their localmaternal and child health clinic for further follow-up.

A patient and her infant should only be discharged if they areboth well and have been referred to the local maternal andchild health clinic, and the patient has received contraceptivecounselling.

6-16 What additional management is needed for HIV-positivepatients?

1. Patients that do not require antiretroviral treatment (CD4 count 250 cells/mlor more and stage 1 or 2 disease) must be encouraged to attend their nearestclinic for a clinical assessment and CD4 count every 6 months.

2. Patients on antiretroviral treatment must be encouraged to be compliant withregular clinic visits and adherence to medication.

3. Blood must be taken from the infant for a DNA PCR test and an appointmentmade so that the infant’s result can be obtained and further managementplanned. The DNA PCR will determine whether the infant is HIV infected.

4. The essential postpartum care (EPOC) card (Figure 6-1) for the 6 weeks visitcould now be completed.

174 THE PUERPERIUM AND FAMILY PLANNING

Figure 6-1: The essential postpartum care card

Puerperal pyrexia6-17 When is puerperal pyrexia present?A patient has puerperal pyrexia if her oral temperature rises to 38 °C orhigher during the puerperium.

6-18 Why is puerperal pyrexia important?Because it may be caused by serious complications of the puerperium.Breastfeeding may be interfered with. The patient may become very ill oreven die.

Puerperal pyrexia may be caused by a serious complication ofthe puerperium.

PUERPERAL PYREXIA 175

6-19 What are the causes of puerperal pyrexia?1. Genital tract infection.2. Urinary tract infection.3. Mastitis or breast abscess.4. Thrombophlebitis (superficial vein thrombosis).5. Respiratory tract infection.6. Other infections.

6-20 What is the cause of genital tract infection?Genital tract infection (or puerperal sepsis) is caused by bacterial infection ofthe raw placental site or lacerations of the cervix, vagina or perineum.

6-21 How should you diagnose genital tract infection?1. History. If one or more of the following is present:◦ Preterm or prelabour rupture of the membranes, a long labour, operative

delivery or incomplete delivery of the placenta or membranes may haveoccurred.

◦ The patient will feel generally unwell.◦ Lower abdominal pain.

2. Examination.◦ Pyrexia, usually developing within the first 24 hours after delivery. Rigors

may occur.◦ Marked tachycardia.◦ Lower abdominal tenderness.◦ Offensive lochia.◦ The episiotomy wound or perineal or vaginal tears may be infected.

6-22 How should you manage genital tract infection?These patients require admission to a hospital urgently and must be referred.While waiting to be transferred treatment could be initiated:

• Measures to bring down the temperature, e.g. tepid sponging.• Analgesia, e.g. paracetamol (Panado) 1 g (2 adult tablets) orally 6 hourly.• Intravenous fluids.• Broad-spectrum antibiotics, e.g. ampicillin and metronidazole (Flagyl).

Antibiotic treatment must be started before transfer.

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6-23 How must a patient with offensive lochia be managed?1. If the patient has a pyrexia she must be admitted to hospital.2. If the patient has a normal temperature and normal involution of her uterus,

she can be managed as an out patient with oral ampicillin and metronidazole(Flagyl).

Offensive lochia is an important sign of genital tract infection.

6-24 How should you diagnose a urinary tract infection?1. History.◦ The patient may have been catheterised during labour or in the puerperium.◦ Lower abdominal pain and/or pain in the lower back over one or both the

kidneys (the loins).◦ Dysuria and frequency. However, these are not reliable symptoms of urinary

tract infection.

2. Examination.◦ Pyrexia, often with rigors (shivering).◦ Tachycardia.◦ Suprapubic and flank tenderness and/or tenderness, especially to light

percussion, over the kidneys (punch tenderness in the renal angles).

3. Side room and special investigations.◦ Microscopy of a midstream or catheter specimen of urine usually shows large

numbers of pus cells and bacteria.◦ Culture and sensitivity tests of the urine must be done if the facilities are

available.

The presence of pyrexia and punch tenderness in the renal angles indicates anupper renal tract infection and a diagnosis of acute pyelonephritis must bemade.

PUERPERAL PYREXIA 177

6-25 How should you manage a patient with a urinary tractinfection?

1. PreventionAvoid catheterisation whenever possible. If catheterisation is essential, itmust be done with strict aseptic precautions.

2. Treatment.These patients require admission to a hospital urgently and must be referred.While waiting to be transferred treatment could be initiated:

◦ Measures to bring down the temperature, e.g. tepid sponging.◦ Analgesia, e.g. paracetamol (Panado) 1 g (2 adult tablets) orally 6 hourly.◦ Intravenous fluids.

Antibiotics should not be given to a patient with puerperalpyrexia until she has been fully investigated.

6-26 What is superficial vein thrombophlebitis?This is a non-infective inflammation and thrombosis of the superficial veinsof the leg or forearm where an infusion was given. Thrombophlebitiscommonly occurs during the puerperium, especially in varicose veins.

6-27 How should you diagnose superficial leg veinthrombophlebitis?

1. History.◦ Painful swelling of the leg or arm.◦ Presence of varicose veins.

2. Examination.◦ Pyrexia.◦ Tachycardia.◦ Presence of a localised area of the leg or arm which is swollen, red and

tender.

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6-28 How should you manage a patient with superficial veinthrombophlebitis?

1. Give analgesia, e.g. aspirin 300 mg (1 adult tablet) 6 hourly.2. Support the leg with an elastic bandage.3. Encourage the patient to walk around.

6-29 How should you diagnose a lower respiratory tract infection?A lower respiratory tract infection, such as acute bronchitis or pneumonia, isdiagnosed as follows:

1. History.◦ The patient may have had general anaesthesia with endotracheal intubation,

e.g. for a caesarean section.◦ Cough, which may be productive.◦ Pain in the chest.◦ A recent upper respiratory tract infection.

2. Examination.◦ Pyrexia.◦ Tachypnoea (breathing rapidly).◦ Tachycardia.

3. Special investigations.◦ A chest X-ray is useful in diagnosing pneumonia.

6-30 How should you manage a patient with a lower respiratorytract infection?

1. TreatmentThese patients require admission to a hospital urgently and must be referredunless the infection is very mild. While waiting to be transferred treatmentcould be initiated:

◦ Oxygen if required.◦ Ampicillin orally or intravenously depending on the severity of the infection.◦ Analgesia, e.g. paracetamol (Panado) 1 g.

2. Special investigationsSend a sample of sputum for microscopy, culture and sensitivity testing ifpossible.

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6-31 Which other infections may cause puerperal pyrexia?Tonsillitis, influenza and any other acute infection, e.g. acute appendicitis ormeningitis.

6-32 What should you do if a patient presents with puerperalpyrexia?

1. Ask the patient what she thinks is wrong with her.2. Specifically ask for symptoms which point to:◦ An infection of the throat or ears.◦ Mastitis or breast abscess.◦ A chest infection.◦ A urinary tract infection.◦ An infected abdominal wound if the patient had a caesarean section or a

puerperal sterilisation.◦ Genital tract infection.◦ Superficial leg vein thrombophlebitis.

3. Examine the patient systematically, including the:◦ Throat and ears.◦ Breasts.◦ Chest.◦ Abdominal wound, if present.◦ Urinary tract.◦ Genital tract.◦ Legs, especially the calves.

4. Perform the necessary special investigations, but always send off a:◦ Endocervical swab.◦ Midstream or catheter specimen of urine.

5. Start the appropriate treatment.

If a patient presents with puerperal pyrexia the cause of thepyrexia must be found and appropriately treated.

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Puerperal psychiatric disorders6-33 Which are the puerperal psychiatric disorders?

1. The ‘puerperal blues’.2. Temporary postnatal depression.3. Puerperal psychosis.

6-34 Why is it important to recognise the various puerperalpsychiatric disorders?

1. The ‘puerperal blues’ are very common in the first week after delivery,especially on day 3. The patient feels miserable and cries easily. Although thepatient may be very distressed, all that is required is an explanation,reassurance, and a caring, sympathetic attitude and emotional support. Thecondition improves within a few days.

2. Postnatal depression is much more common than is generally realised. Theonset is later than ‘puerperal blues’ and it may last for months or even years.The patients may need to be referred to a psychiatrist. Patients with postnataldepression usually present with a depressed mood that cannot be relieved, alack of interest in their surroundings, a poor or excessive appetite, sleepingdifficulties, feelings of inadequacy, guilt and helplessness, and sometimessuicidal thoughts.

3. Puerperal psychosis is an uncommon but very important condition. The onsetis usually acute and an observant attendant will notice the sudden andmarked change in the patient’s behaviour. She may rapidly pose a threat toher infant, the staff and herself. Such a patient must be referred urgently to apsychiatrist and will usually need admission to a psychiatric unit. Patientswith puerperal psychosis are unable to care for themselves or their infants.They are often disoriented and paranoid and may have hallucinations. Theymay also be severely depressed or manic.

PUERPERAL PSYCHIATRIC DISORDERS 181

Secondary postpartum haemorrhage6-35 What is secondary postpartum haemorrhage?This is any amount of vaginal bleeding, other than the normal amount oflochia, occurring after the first 24 hours postpartum until the end of thepuerperium. It commonly occurs between the fifth and fifteenth days afterdelivery.

6-36 Why is secondary postpartum haemorrhage important?1. A secondary postpartum haemorrhage may be so severe that it causes shock.2. Unless the cause of the secondary postpartum haemorrhage is treated, the

vaginal bleeding will continue.

6-37 What are the causes of secondary postpartum haemorrhage?1. Genital tract infection with or without retention of a piece of placenta or part

of the membranes. This is the commonest cause.2. Separation of an infected slough in a cervical or vaginal laceration.3. Breakdown (dehiscence) of a caesarean section wound of the uterus.

However, the cause is unknown in up to half of these patients.

6-38 What clinical features should alert you to the possibility of thepatient developing secondary postpartum haemorrhage?

1. A history of incomplete delivery of the placenta and/or membranes.2. Unexplained puerperal pyrexia.3. Delayed involution of the uterus.4. Offensive and/or persistently red lochia.

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6-39 How should you manage a patient with secondary postpartumhaemorrhage?

1. Treatment. These patients require admission to a hospital and must bereferred unless the haemorrhage is very mild. While waiting to be transferredtreatment could be initiated:

◦ Review of the clinical notes with regard to completeness of the placenta andmembranes.

◦ Obtain an endocervical swab for bacteriology.◦ Give ampicillin and metronidazole (Flagyl) orally.◦ Give Syntometrine 1 ml intramuscularly or 20 units oxytocin in an

intravenous infusion if excessive haemorrhage is present.

6-40 What may you find on physical examination to suggest thatretained pieces of placenta or membranes are the cause of asecondary postpartum haemorrhage?

1. The uterus will be involuting slower than usual.2. Even though the patient may be more than 7 days postpartum, the cervical os

will have remained open and a finger can be passed through the cervix.

Self-monitoring6-41 What is meant by the concept of ‘the mother as a monitor’?This is a concept where the patient is made aware of the many ways in whichshe can monitor her own, as well as her fetus’ or infant’s wellbeing, duringpregnancy, in labour and in the puerperium. This has two major advantages:

1. The patient becomes much more involved in her own perinatal care.2. Possible complications will be reported by the patient at the earliest

opportunity.

6-42 How can the patient act as a monitor in the puerperium?The patient must be encouraged to report the following complications assoon as she becomes aware of them:

SELF-MONITORING 183

1. Maternal complications.◦ Symptoms of puerperal pyrexia.◦ Breakdown of an episiotomy.◦ Breastfeeding problems.◦ Excessive or offensive lochia.◦ Recurrence of vaginal bleeding, i.e. secondary postpartum haemorrhage.◦ Prolonged postnatal depression.

2. Complications in the infant.◦ Poor feeding or other feeding problems.◦ Lethargy.◦ Jaundice.◦ Conjunctivitis.◦ Infection of the umbilical cord stump.

Each patient must be taught to monitor her own wellbeing, aswell as that of her fetus or infant.

Family planning in the puerperium6-43 What is family planning?Family planning is far more than simply birth control, and aims at improvingthe quality of life for everybody. Family planning is an important part ofprimary health care and includes:

1. Promoting a caring and responsible attitude to sexual behaviour.2. Ensuring that every child is wanted.3. Encouraging the planning and spacing of the number of children according to

a family’s home conditions and financial income.4. Providing the highest quality of maternal and child care.5. Educating the community with regard to the disastrous effects of unchecked

population growth on the environment.

It is essential to obtain prior community acceptance of, and promotecommunity participation in, any family planning programme if theprogramme is to succeed in that community.

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6-44 Who requires family planning education?Because family planning aims at improving the quality of life for everybody,every person, female or male, requires family planning education. Sucheducation should ideally start during childhood and be given in the home bythe parents. It is then continued at school and throughout the rest of theindividual’s life.

6-45 Who needs contraceptive counselling?Every person who is sexually active, or who probably will soon becomesexually active, needs contraceptive counselling (i.e. information and adviceabout birth control). While the best time to advise a woman on contraceptionis before the first coitus, the antenatal and postdelivery periods provide anexcellent opportunity to provide contraceptive counselling. Some patientswill ask you for contraceptive advice. However, you will often have to firstmotivate a patient to accept contraception before you can advise her about anappropriate method of contraception.

6-46 How should you motivate a patient to accept contraceptionafter delivery?A good way to motivate a patient to accept contraception is to discuss withher, or preferably with both her and her partner, the health and socio-economic effects further children could have on her and the rest of the family.Explain the immediate benefits of a smaller, well-spaced family.

It is generally hopeless to try and promote contraception by itself. To gainindividual and community support, family planning must be seen as part oftotal primary health care. A high perinatal or infant mortality rate in acommunity is likely to result in a rejection of contraception.

6-47 How should you give contraceptive advice after delivery?There are 5 important steps which should be followed:

Step 1: Discussion of the patient’s future reproductive career

Ideally a woman should consider and plan her family before her firstpregnancy, just as she would have considered her professional career.Unfortunately in practice this hardly ever happens and many women only

FAMILY PLANNING IN THE PUERPERIUM 185

discuss their reproductive careers for the first time when they are alreadypregnant or after the birth of the infant.

When planning her family the woman (or preferably the couple) shoulddecide on:

1. The number of children wanted.2. The time intervals between pregnancies as this will influence the method of

contraception used.3. The contraceptive method of choice when the family is complete.

Very often the patient will be unable or unwilling to make these decisionsimmediately after delivery. However, it is essential to discuss contraceptionwith the patient so that she can plan her family. This should be done togetherwith her husband and, where appropriate, other members of her family orfriends.

Step 2: The patient’s choice of a contraceptive method

The patient should always be asked which contraceptive method she wouldprefer as this will obviously be the method with which she is most likely tocontinue.

Step 3: Consideration of contraindications to the patient’s preferredmethod

You must decide whether the patient’s choice of a contraceptive method issuitable, taking into consideration:

1. The effectiveness of each contraceptive method.2. The contraindications to each contraceptive method.3. The side effects of each contraceptive method.4. The general health benefits of each contraceptive method.

If the contraceptive efficiency of the preferred method is appropriate, if thereare no contraindications to it, and if the patient is prepared to accept thepossible side effects, then the method chosen by the patient should be used.Otherwise proceed to step 4.

Step 4: Selection of the most appropriate alternative method ofcontraception

The selection of the most suitable alternative method of contraception afterdelivery will depend on a number of factors including the patient’s wishes,

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her age, the risk of side effects and whether or not a very effective method ofcontraception is required.

Step 5: Counselling the patient once the contraceptive method hasbeen chosen

Virtually every contraceptive method has its own side effects. It is a mostimportant part of contraceptive counselling to explain the possible sideeffects to the patient. Expert family planning advice must be sought if thelocal clinic is unable to deal satisfactorily with the patient’s problem. If familyplanning method problems are not satisfactorily solved, the patient willprobably stop using any form of contraception.

After delivery the reproductive career of each patient must bediscussed with her in order to decide on the most appropriatemethod of family planning to be used.

6-48 What contraceptive methods can be offered after delivery?1. Sterilisation. Either tubal ligation (tubal occlusion) or vasectomy.2. Injectables (i.e. an intramuscular injection of depot progestogen).3. Oral contraceptives. Either the combined pill (containing both oestrogen and

progestogen) or a progestogen-only pill (the ‘minipill’).4. An intra-uterine contraceptive device (IUCD).5. The condom.

Breastfeeding, spermicides alone, coitus interruptus and the ‘safe period’ areall very unreliable. All women should know about postcoital contraception.

Breastfeeding cannot be relied upon to provide postpartumcontraception.

6-49 How effective are the various contraceptive methods?Contraceptive methods for use after delivery may be divided into veryeffective and less effective ones. Sterilisation, injectables, oral contraceptivesand intra-uterine contraceptive devices are very effective. Condoms are lesseffective contraceptives.

FAMILY PLANNING IN THE PUERPERIUM 187

6-50 How effective is postcoital contraception?1. Norlevo, E Gen-C or Ovral are effective within 5 days of unprotected sexual

intercourse, but are more reliable the earlier they are used.2. A copper intra-uterine contraceptive device can be inserted within 6 days of

unprotected intercourse.3. Postcoital methods should only be used in an emergency and not as a regular

method of contraception.4. If Norlevo is used, one tablet should be taken as soon as possible after

intercourse, followed by another one tablet after exactly 12 hours.5. If Ovral or E-Gen-C is used, two tablets are taken as soon as possible after

intercourse, followed by another two tablets exactly 12 hours later.

The tablets for postcoital contraception often cause nausea and vomitingwhich reduce their effectiveness. These side effects are less with Norlevowhich contains no oestrogen. Therefore Norlevo is a more reliable methodand should be used if available. Norlevo as a single dose method is availableand on code in the public sector in South Africa.

6-51 What are the contraindications to the various contraceptivemethods?The following are the common or important conditions where the variouscontraceptive methods should not be used:

1. Sterilisation:◦ Marital disharmony.◦ Psychological problems.◦ Forced or hasty decision.◦ Gynaecological problem requiring hysterectomy.

2. Injectables:◦ Depression.◦ Pregnancy planned within 1 year.

3. Combined pills:◦ A history of venous thrombo-embolism.◦ Age 35 years or more with risk factors for cardiovascular disease (i.e.

smoking).◦ Anyone of 50 or more years.

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◦ Oestrogen-dependent malignancies such as breast or uterine cancer.◦ HIV positive women on ART that includes a protease inhibitor (PI).

Lopinavir/ritonavir is a PI commonly used as a second line ARV regimen.

4. Progestogen-only pill (minipill):◦ None.

5. Copper-containing intra-uterine contraceptive device:◦ A history of excessive menstruation.◦ Anaemia.◦ Multiple sex partners when the risk of genital infection is high.◦ Pelvic inflammatory disease.◦ Immuno-compromised patients (i.e. AIDS with stage 4 disease).

A menstrual abnormality is a contra-indication to any of the hormonalcontraceptive methods (injectables, combined pill or progestogen-only pill)until the cause of the menstrual irregularity has been diagnosed. Thereafter,hormonal contraception may often be used to correct the menstrualirregularity. However, during the puerperium a previous history of menstrualirregularity before the pregnancy is not a contraindication to hormonalcontraception.

6-52 What are the major side effects of the various contraceptivemethods?Most contraceptive methods have side effects. Some side effects areunacceptable to a patient and will cause her to discontinue the particularmethod. However, in many instances side effects are mild or disappear withtime. It is, therefore, very important to counsel a patient carefully about theside effects of the various contraceptive methods, and to determine whethershe would find any of them unacceptable. At the same time the patient maybe reassured that some other side effects will most likely become less ordisappear after a few months’ use.

The major side effects of the various contraceptive methods used afterdelivery are:

1. Sterilisation:◦ Tubal ligation and vasectomy have no medical side effects and, therefore,

should be highly recommended during counselling of patients who have

FAMILY PLANNING IN THE PUERPERIUM 189

completed their families. Menstrual irregularities are NOT a problem.However, about 5% of women later regret sterilisation.

2. Injectables:◦ Menstrual abnormalities, e.g. amenorrhoea, irregular menstruation or

spotting.◦ Weight gain.◦ Headaches.◦ Delayed return to fertility within a year of stopping the method. There is no

evidence that fertility is reduced thereafter.

3. Combined pill:◦ Reduction of lactation.◦ Menstrual abnormalities, e.g. spotting between periods.◦ Nausea and vomiting.◦ Depression.◦ Fluid retention and breast tenderness.◦ Chloasma (a brown mark on the face).◦ Headaches and migraine.

4. Progestogen-only pill:◦ Menstrual abnormalities, e.g. irregular menstruation.◦ Headaches.◦ Weight gain.

5. Intra-uterine contraceptive device:◦ Expulsion in 5–15 cases per 100 women who use the device for one year.◦ Pain at insertion.◦ Dysmenorrhoea.◦ Menorrhagia (excessive and/or prolonged bleeding).◦ Increase in pelvic inflammatory disease.◦ Perforation of the uterus is uncommon.◦ Ectopic pregnancy is not prevented.◦ Progesterone-containing devices (Mirena) have fewer side effects and reduce

menstrual blood loss. These devices are expensive and not generally availablein the public health sector facilities.

6. Condom:◦ Decreased sensation for both partners.◦ Not socially acceptable to everyone.

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If a couple have completed their family the contraceptivemethod of choice is tubal ligation or vasectomy.

Additional contraceptive precautions must be taken when the contraceptiveeffectiveness of an oral contraceptive may be impaired, e.g. diarrhoea orwhen taking antibiotics. There is no medical reason for stopping a hormonalmethod periodically to ‘give the body a rest’.

6-53 What are the important health benefits of contraceptives?The main objective of all contraceptive methods is to prevent pregnancy. Indeveloping countries pregnancy is a major cause of mortality and morbidityin women. Therefore, the prevention of pregnancy is a very importantgeneral health benefit of all contraceptives.

Various methods of contraception have a number of additional healthbenefits. Although these benefits are often important, they are not generallyappreciated by many patients and health-care workers:

1. Injectables:◦ Decrease in dysmenorrhoea.◦ Less premenstrual tension.◦ Less iron-deficiency anaemia due to decreased menstrual flow.◦ No effect on lactation.

2. Combined pill:◦ Decrease in dysmenorrhoea.◦ Decrease in menorrhagia (heavy and/or prolonged menstruation).◦ Less iron-deficiency anaemia.◦ Less premenstrual tension.◦ Fewer ovarian cysts.◦ Less benign breast disease.◦ Less endometrial and ovarian carcinoma.

FAMILY PLANNING IN THE PUERPERIUM 191

3. Progestogen-only pill:◦ No effect on lactation.

4. Condom:◦ Less risk of HIV infection and other sexually transmitted diseases.◦ Less pelvic inflammatory disease.◦ Less cervical intra-epithelial neoplasia.

The condom is the only contraceptive method that providesprotection against HIV infection.

6-54 What is the most appropriate method of contraception for apatient after delivery?The most suitable methods for the following groups of patients are:

1. Lactating patients:◦ An injectable, but not if a further pregnancy is planned within the next year.◦ A progestogen-only pill (minipill) for 3 months, then the combined pill.◦ An intra-uterine contraceptive device. Non-lactating patients can start the

combined pill following one month’s use of a progesterone-only pill.

2. Teenagers and patients with multiple sexual partners:◦ An injectable, as this is a reliable method even with unreliable patients who

might forget to use another method.◦ Additional protection against HIV infection by using a condom is essential. It

is important to stress that the patient should only have intercourse with apartner who is willing to use a condom.

3. HIV-positive patients:◦ Condoms must be used in addition to the appropriate contraceptive method

(dual contraception).

4. Patients whose families are complete:◦ Tubal ligation or vasectomy is the logical choice.◦ An injectable, e.g. Depo-Provera or Petogen (12 weekly) or Nur-Isterate (8

weekly).◦ A combined pill until 35 years of age if there are risk factors for

cardiovascular disease, or until 50 years if these risk factors are absent.

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5. Patients of 35 years or over without risk factors for cardiovascular disease:◦ Tubal ligation or vasectomy is the logical method.◦ A combined pill until 50 years.◦ An injectable until 50 years of age.◦ A progestogen-only pill until 50 years of age.◦ An intra-uterine contraceptive device until 1 year after the periods have

stopped, i.e. when there is no further risk of pregnancy.

6. Patients of 35 years or over with risk factors for cardiovascular disease:◦ As above but NO combination pill.

The puerperium is the most convenient time for the patient tohave a bilateral tubal ligation performed.

Every effort should be made to provide facilities for tubal ligation during thepuerperium for all patients who request sterilisation after delivery.

Remember that sperms may be present in the ejaculate for up to 3 monthsfollowing vasectomy. Therefore, an additional contraceptive method must beused during this time.

6-55 What are the risk factors for cardiovascular disease in womentaking the combined pill?The risk of cardiovascular disease increases markedly in women of 35 or moreyears of age who have 1 or more of the following risk factors:

1. Smoking.2. Hypertension.3. Diabetes.4. Hypercholesterolaemia.5. A personal history of cardiovascular disease.

Smoking is a risk factor for cardiovascular disease.

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6-56 When should an intra-uterine contraceptive device be insertedafter delivery?It should not be inserted before 6 weeks as the uterine cavity would not yethave returned to its normal size. At 6 weeks or more after delivery there isthe lowest risk of:

1. Pregnancy.2. Expulsion.

Postpartum patients choosing this method must be discharged on aninjectable contraceptive or progestogen-only pill until an intra-uterinecontraceptive device has been inserted.

Case study 1A patient returns to a clinic for a visit 3 days after a normal first pregnancyand delivery. She complains of leaking urine when coughing or laughing, andshe is also worried that she has not passed a stool since the delivery. Shestarts to cry and says that she should not have fallen pregnant. Her infanttakes the breast well and sleeps well after each feed. On examination thepatient appears well, her observations are normal, the uterus is the size of a16 week pregnant uterus, and the lochia is red and not offensive.

1. Is her puerperium progressing normally?Yes. The patient appears healthy with normal observations, and theinvolution of her uterus is satisfactory.

2. What should be done about the patient’s complaints?Stress incontinence is common during the puerperium. Therefore, the patientmust be reassured that it will improve over time. However, pelvic floorexercises must be explained to her as they will hasten improvement of herincontinence. She need not be worried about not having passed a stool as thisis normal during the first few days of the puerperium.

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3. Why is the patient regretting her pregnancy and crying for noapparent reason?She probably has the ‘puerperal blues’ which are common in the puerperium.Listen sympathetically to the patient’s complaints and reassure her that she ismanaging well as a mother. Also explain that her feelings are normal and areexperienced by most mothers.

4. What educational topics must be discussed with the patientduring this visit?

1. Family size and when she plans to have her next infant.2. Which contraceptive method she should use and how to use it correctly.3. The care and feeding of her infant, stressing the importance of breastfeeding.4. Symptoms of a genital tract infection, i.e. offensive lochia, fever and lower

abdominal pain.5. The time that coitus can be resumed.

Also ask about, and discuss, any other uncertainties which the patient mayhave.

Case study 2Following a prolonged first stage of labour due to an occipito-posteriorposition, a patient has a spontaneous vertex delivery in hospital. The placentaand membranes are complete. There is no excessive postpartum blood lossand the patient is discharged home after 6 hours. Within 24 hours of deliverythe patient is brought back to the clinic nearest to her home. She has atemperature of 39 °C, a pulse rate of 110 beats per minute and complains of aheadache and lower abdominal pain. The uterus is tender to palpation.

1. What does the patient present with?Puerperal pyrexia.

2. What is the most likely cause of the puerperal pyrexia?Genital tract infection, i.e. puerperal sepsis. This diagnosis is suggested by thegeneral signs of infection and the uterine tenderness. The patient had a

CASE STUDY 2 195

prolonged first stage of labour, which is usually accompanied by a greaterthan usual number of vaginal examinations and, therefore, predisposes togenital tract infection.

3. Was the early postnatal management of this patient correct?No. The patient should not have been discharged home so early as she had aprolonged first stage of labour which places her at a higher risk of infection.She should have been observed for at least 24 hours.

4. How should you manage this patient further in the clinic?She must be made comfortable. Paracetamol (Panado) 1 g orally may be givenfor the headache. If necessary she should be given a tepid sponging. Anintravenous infusion should be started and she must then be referred tohospital. If at all possible the infant must accompany the patient to hospital.The need to start antibiotic treatment, e.g. intravenous ampicillin and oralmetronidazole (Flagyl), before transfer must be discussed with the doctor.

Case study 3A patient is seen at a clinic on day 5 days following a normal pregnancy,labour and delivery. She complains of rigors and lower abdominal pain. Shehas a temperature of 38.5 °C, tenderness over both kidneys (loins) andtenderness to percussion over both renal angles. A diagnosis of puerperalpyrexia is made and the patient is given oral ampicillin. She is asked to comeback to the clinic on day 7.

1. Are you satisfied with the diagnosis of puerperal pyrexia?No. Puerperal pyrexia is a clinical sign and not a diagnosis. The cause of thepyrexia must be found by taking a history, doing a physical examination and,if indicated, completing special investigations.

2. What is the most likely cause of the patient’s pyrexia?An upper urinary tract infection as suggested by the pyrexia, rigors, lowerabdominal pain and tenderness over the kidneys.

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3. Do you agree with the management given to the patient?No. A urinary tract infection that causes puerperal pyrexia is an indicationfor admitting the patient to hospital. An intravenous broad-spectrumantibiotic (ampicillin or cefuroxime) must be given as this will lead to a rapidrecovery and prevent serious complications.

4. Why is a puerperal patient at risk of a urinary tract infection andhow may this be prevented?Catheterisation is often required and this increases the risk of a urinary tractinfection. Catheterisation must only be carried out when necessary and mustalways be done as an aseptic procedure.

Case study 4A 36 year old woman that delivered her fourth child in a midwife obstetricunit the previous day is seen at a clinic for postnatal care. All her children arealive and well. She is a smoker but is otherwise healthy. She has never usedcontraception.

1. Should you counsel this patient about contraception?Yes. Every sexually active person needs contraceptive counselling. Thispatient in particular needs counselling as she is at an increased risk ofmaternal and perinatal complications, should she fall pregnant again, becauseof her age and parity.

2. Which contraceptive methods would be appropriate for thispatient?Tubal ligation or vasectomy would be the most appropriate method ofcontraception if she does not want further children. Should she not wantsterilisation, either an injectable contraceptive or an intra-uterinecontraceptive device would be the next best choice.

CASE STUDY 4 197

3. If the patient accepts tubal ligation, when should this be done?The most convenient time for the patient and her family is shortly afterdelivery (postpartum sterilisation). Every effort should be made to providefacilities for postpartum sterilisation for all patients who request it.

4. If the couple decides not to have a tubal ligation or vasectomy,how will you determine whether an injectable or an intra-uterinecontraceptive device would be the best choice?Assessing the risk for pelvic inflammatory disease will determine which ofthe 2 methods to use. If the patient has a stable relationship, an intra-uterinecontraceptive device may be more appropriate. However, if she or herhusband (or boyfriend) has other sexual partners, an injectable contraceptivewould be indicated.

5. What other advice must be given to a patient at risk of sexuallytransmitted infections?The patient must insist that her partner wears a condom during sexualintercourse. This will reduce the risk of HIV infection.

Case study 51. Does this young teenager require contraceptive advice afterdelivery?Yes, she will certainly need contraceptive counselling. She needs to learnsexual responsibility and must be told to attend a family planning clinic. Shealso needs to know about postcoital contraception.

2. Which contraceptive method would be most the appropriate forthis patient?An injectable contraceptive would probably be the best method for her as sheneeds reliable contraception for a long time.

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3. Why would she need a long-term contraceptive?Because she should only have her next child when she is much older and hasa stable relationship.

4. If the patient prefers to use an oral contraceptive, would youregard this as an appropriate method of contraception for her?No. A method which she is more likely to use correctly and reliably would bemore appropriate. Oral contraceptives are only reliable if taken every day.

5. The patient and her mother are worried that the long-term effectof injectable contraception could be harmful to a girl of 15 years.What would be your advice?Injectable contraception is extremely safe and, therefore, is an appropriatemethod for long-term use. This method will not reduce her future fertility.

Case study 6A healthy 32 year old woman visits a clinic for postnatal care. She had anormal delivery 3 days ago. In discussing contraception with her, shementions that she is planning to fall pregnant again within a year after shestops breastfeeding. She is a school teacher and would like to continue hercareer after having 2 children.

1. The patient says that she has used an injectable contraceptivefor 5 years before this pregnancy and would like to continue withthis method. What would your advice be?Injectable contraception would not be appropriate as she plans her nextpregnancy within a year, and there may be a delayed return to fertility.

2. If the patient insists on using an injectable contraceptive, whichdrug would you advise her to use?Any one of the injectables can be used (Depo Provera, Petogen or Nur-Isterate) could be used as there is no proven advantage of any one above theothers.

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3. Following further counselling, the patient decides on oralcontraception and is given a combined pill. Do you agree with thismanagement?No. As she plans to breastfeed, she should be given a progestogen-only pill.Combined oral contraceptive pills may reduce milk production whilebreastfeeding is being established. Progestogen-only pills have no effect onbreastfeeding and must be used at least for the first 3 months followingdelivery of her baby.

Case study 7A married primipara from a rural area has just been delivered in hospital. Shehas a stable relationship with her husband and they decide to have their nextinfant in 5 years time. The patient would like to have an intra-uterinecontraceptive device inserted.

1. Is this an appropriate method for this patient?Yes, as the risk of developing pelvic inflammatory disease is low.

2. When should the device be inserted?Six weeks or more after delivery as there is an increased risk of expulsion ifthe device is inserted earlier.

3. Could the patient, in the meantime, rely on breastfeeding as acontraceptive method?No. The risk of pregnancy is too high. She should use reliable contraception,such as injectable contraception or the progestogen-only pill, until the deviceis inserted.

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7Medical problems duringpregnancy and thepuerperiumBefore you begin this unit, please take the corresponding test to assess yourknowledge of the subject matter. You should redo the test after you’veworked through the unit, to evaluate what you have learned.

ObjectivesWhen you have completed this unit you should be able to:

• Diagnose and manage cystitis.• Reduce the incidence of acute pyelonephritis in pregnancy.• Diagnose acute pyelonephritis in pregnancy.• Diagnose and manage anaemia during pregnancy.• Identify patients who may possibly have heart valve disease.• Manage a patient who develops glycosuria during pregnancy.• Manage women needing antiretroviral treatment.

Urinary tract infection during pregnancy7-1 Which urinary tract infections are important during pregnancy?

1. Cystitis.2. Asymptomatic bacteriuria.3. Acute pyelonephritis.

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7-2 Why are urinary tract infections common during pregnancy andthe puerperium?

1. Placental hormones cause dilatation of the ureters.2. Pregnancy suppresses the function of the immune system.3. Catheterisation during the first and second stage of labour is common.

A urinary tract infection is the most common infection duringpregnancy.

7-3 How is cystitis diagnosed?1. Severe urinary symptoms suddenly appear:◦ Dysuria (pain on passing urine).◦ Frequency (having to pass urine often).◦ Nocturia (having to get up at night to pass urine).

2. The patient appears generally well with normal observations. The onlyclinical sign is tenderness over the bladder.

3. Examination of the urine under a microscope shows many pus cells andbacteria.

A midstream urine sample for culture must be collected, if possible, toconfirm the clinical diagnosis. Treatment must commence immediatelywithout waiting for the results of the culture.

7-4 How should you manage a patient with cystitis?Give 4 adult tablets of co-trimoxazole (e.g. Bactrim, Co-Trim, Durobac,Mezenol or Purbac) as a single dose. This is also the drug of choice forpatients who are allergic to penicillin.

Amoxycillin (Amoxil) 3 g as a single dose orally could also be used butorganisms causing cystitis are often resistant to this antibiotic. The treatmentwill be more successful if 2 amoxycillin capsules (250mg) are replaced with 2Augmentum tablets that contain an added 125 mg clavulanic acid each.

A midstream sample should be sent for culture and sensitivity at the nextantenatal visit to determine whether the management was successful.

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Co-trimoxazole can be safely used during pregnancy, including the firsttrimester.

7-5 What is asymptomatic bacteriuria?It is significant colonisation of the urinary tract with bacteria, without anysymptoms of a urinary tract infection.

7-6 Why is asymptomatic bacteriuria during pregnancy important?1. Between 6 and 10% of pregnant women have asymptomatic bacteriuria.2. One third of these patients with asymptomatic bacteriuria will develop acute

pyelonephritis during pregnancy.3. If patients with asymptomatic bacteriuria are diagnosed and correctly

managed, their risk of developing acute pyelonephritis will be reduced by70%.

4. The risk for preterm labour is significantly increased with asymptomaticbacteriuria.

The diagnosis and treatment of asymptomatic bacteriuria willgreatly reduce the incidence of acute pyelonephritis andpreterm labour during pregnancy.

7-7 How and when should patients be screened for asymptomaticbacteriuria?If possible, bacterial culture of a midstream urine sample should be done atthe first antenatal visit to screen patients for asymptomatic bacteriuria.

If possible, a screening test for asymptomatic bacteriuriashould be done at the first antenatal visit.

7-8 Can reagent strips be reliably used to diagnose asymptomaticbacteriuria?No. Tests for nitrites (which detect the presence of bacteria) and leukocytes,separately or together, cannot be used to accurately screen for asymptomaticbacteriuria.

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7-9 What is the management of a patient with asymptomaticbacteriuria?The same as the management of a patient with cystitis, i.e. 4 adult tablets ofco-trimoxazole (e.g. Bactrim, Septran) as a single dose or amoxycillin(Amoxil) 3 g as a single dose orally. Patients who are allergic to penicillinshould be given co-trimoxazole.

A midstream specimen of urine should again be sent for microscopy, cultureand sensitivity at the next antenatal visit to determine whether themanagement was successful.

7-10 What symptoms suggest acute pyelonephritis?1. Most patients have severe general symptoms:◦ Headache.◦ Pyrexia and rigors (shivering).◦ Lower backache, especially pain over the kidneys (renal angles).

2. Only 40% of patients have urinary complaints.

7-11 What physical signs are usually found in a patient with acutepyelonephritis?

1. The patient is acutely ill.2. The patient usually has high pyrexia and a tachycardia. However, the

temperature may be normal during rigors.3. On abdominal examination, the patient is tender over one or both kidneys.

The patient is also tender on light percussion over one or both renal angles(posteriorly over the kidneys).

7-12 What is the management of a patient with acutepyelonephritis?

1. The patient must be admitted to hospital.2. A midstream urine sample for culture and sensitivity must be collected if

possible to confirm the clinical diagnosis, identify the bacteria and determinethe antibiotic of choice.

3. An intravenous infusion of Balsol or Ringer’s lactate should be started and 1litre given rapidly over 2 hours. Thereafter, 1 litre of Maintelyte should begiven every 8 hours.

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4. An intravenous broad-spectrum antibiotic, e.g. cefuroxime (Zinecef) shouldbe given prior to transfer.

5. Pethidine 100 mg is given intramuscularly for severe pain while paracetamol(Panado) 2 adult tablets can be used for moderate pain.

6. Paracetamol (Panado) 2 adult tablets, together with tepid sponges, are used tobring down a high temperature.

Patients with acute pyelonephritis during pregnancy must beadmitted to hospital for treatment with a broad-spectrumantibiotic.

7-13 Why is acute pyelonephritis a serious infection in pregnancy?Because serious complications can result:

1. Preterm labour.2. Septic shock.3. Perinephric abscess (an abscess around the kidney).4. Anaemia.

7-14 What should be done at the first antenatal visit after thepatient has been treated for acute pyelonephritis?

1. A midstream urine sample for culture and sensitivity must be collected todetermine whether the treatment has been successful.

2. The haemoglobin concentration must be measured as there is a risk ofanaemia developing.

Anaemia in pregnancy7-15 What is the definition of anaemia in pregnancy?A haemoglobin concentration of less than 11 g/dl.

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7-16 What are the dangers of anaemia?1. Heart failure which can result from severe anaemia.2. Shock which may be caused by a relatively small vaginal blood loss

(antepartum haemorrhage, delivery or postpartum haemorrhage) in ananaemic patient.

7-17 What are the common causes of anaemia in pregnancy?1. Iron deficiency as the result of a diet poor in iron.2. Blood loss during pregnancy (also during labour or the puerperium).3. Acute infections (e.g. pyelonephritis), chronic infections (e.g. tuberculosis and

HIV), and infestations (e.g. malaria, bilharzia or hook worm) in regions wherethese occur.

4. Folic acid deficiency is less common.

The commonest cause of anaemia in pregnancy is irondeficiency.

A full blood count, which is sent to the laboratory, will usually identify theprobable cause of the anaemia.

The size and colour of the red cells indicate the probable cause of theanaemia:

1. Microcytic, hypochromic cells suggest iron deficiency.2. Normocytic, normochromic cells suggest bleeding or infection.3. Macrocytic, normochromic cells suggest folate deficiency.

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7-18 What is the management of patients with iron deficiency inpregnancy or the puerperium?

1. The management of iron-deficiency anaemia in pregnancy will depend on thehaemoglobin concentration and the duration of pregnancy:

◦ If the haemoglobin concentration is less than 8 g/dl, the gestational age is lessthan 36 weeks, and the patient is asymptomatic, she can be treated with 2tablets of ferrous sulphate 3 times a day and be followed at the antenatalclinic.

◦ If the haemoglobin concentration is less than 8 g/dl and the gestational age is36 weeks or more, the patient must be admitted to hospital for a bloodtransfusion.

◦ All patients with a haemoglobin concentration of less than 8 g/dl who areshort of breath or have a tachycardia of more than 100 beats per minute(signs of heart failure) must be admitted to hospital for a blood transfusion. Inaddition she must be treated with 2 tablets of ferrous sulphate 3 times a daythat must be continued at least one month after the baby has been delivered.

◦ If the haemoglobin concentration is between 8 g/dl and 10 g/dl, the patientcan be treated with 2 tablets of ferrous sulphate 3 times a day. If thehaemoglobin concentration does not increase after 2 weeks or the patient is36 weeks pregnant or more, and a full blood count has not yet been done,then a full blood count must be done to decide whether the cause of theanaemia is iron deficiency.

◦ If the haemoglobin concentration is 10g/dl or more, but less than 11 g/dl, thepatient can be treated with one tablet of ferrous sulphate 3 times a day.

2. The management of a patient with iron-deficiency anaemia during thepuerperium will depend on whether the patient is bleeding or not:

◦ If the patient is not bleeding, if she has no signs of heart failure, and herhaemoglobin concentration is 6 g/dl or more, she can be treated with oraliron tablets. One tablet of ferrous sulphate 3 times daily for a month issufficient.

◦ If the patient is not bleeding and she has signs of heart failure, or if herhaemoglobin concentration is less than 6 g/dl, she must be admitted tohospital for a blood transfusion to be followed by oral iron for a month.

◦ If the patient is bleeding, she should be managed for a postpartumhaemorrhage.

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7-19 Should all patients receive iron supplements in pregnancy?1. Well-nourished patients who have a healthy diet and a haemoglobin

concentration of 11 g/dl or more, do not need iron supplements.2. Patients who are poorly nourished, have a poor diet or have a haemoglobin

concentration of less than 11 g/dl need iron supplements.3. Patients from communities where iron deficiency is common, or where socio-

economic circumstances are poor, should receive iron supplements.

Iron tablets are dangerous to small children as even one tablet can causeserious iron poisoning. Therefore, patients must always keep their iron tabletsin a safe place where children cannot reach them.

7-20 How are iron supplements given in pregnancy?As 200 mg ferrous sulphate tablets:

1. Patients with a haemoglobin concentration of 11 g/dl or higher must take onetablet daily.

2. Patients who are anaemic must be managed as described in 7-18.

7-21 What side effects can be caused by ferrous sulphate tablets?Nausea and even vomiting due to irritation of the lining of the stomach.

7-22 How should you manage a patient who complains of sideeffects due to ferrous sulphate tablets?

1. The tablets should be taken with meals. Although less iron will be absorbed,the side effects will be less.

2. If the patient continues to complain of side effects, she should be given300 mg ferrous gluconate tablets instead. They cause fewer side effects thanferrous sulphate tablets.

208 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

Figure 7-1: Flow diagram: The management of a patient with iron-deficiencyanaemia in pregnancy

ANAEMIA IN PREGNANCY 209

Heart valve disease in pregnancy and thepuerperiumHeart valve disease consists of damage to, or abnormality of, one or more ofthe valves of the heart. Usually the mitral valve is damaged. The cause ofheart valve disease in a developing country is almost always rheumatic feverduring childhood.

7-23 Why is it important during pregnancy to identify patients withheart valve disease?

1. A correct diagnosis of the type of heart valve disease and good managementof the problem reduces the risk to the patient during her pregnancy.

2. Undiagnosed heart valve disease and inadequate treatment may result inserious complications (e.g. heart failure causing pulmonary oedema) whichmay threaten the patient’s life.

3. A clear family planning plan must be made during the pregnancy. The patientmay have a reduced lifespan and cannot risk having a large family.

Correct diagnosis and good management reduce the risk to thepatient of heart valve disease in pregnancy.

7-24 Which symptoms in a patient’s history suggest that she mayhave heart valve disease?

1. Shortness of breath on exercise or even with limited effort.2. Coughing up blood (haemoptysis).3. Often the patient has previously been told by a doctor that she has a ‘leaking

heart’.4. Some patients with heart valve disease give a history of previous rheumatic

fever. However, most patients are not aware that they have suffered fromprevious rheumatic fever.

The cause of heart valve disease in a developing country is almost alwaysprevious rheumatic fever. However, these patients usually do not know thatthey have had one or more attacks of rheumatic fever during childhood.

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During the examination of the cardiovascular system, a cardiac murmur willbe heard if the patient has heart valve disease.

7-25 How should a patient with heart valve disease in pregnancy bemanaged?

1. The patient must be referred to the high-risk antenatal clinic.2. At the high-risk antenatal clinic the type of lesion and correct management

will be determined.3. The follow-up visits will also be at the high-risk antenatal clinic. However,

the patient may be referred to the primary care antenatal clinic for some‘inbetween’ visits. Take care to follow the instructions from the high-riskclinic carefully.

4. Patients who are not hospitalised should stop work earlier and rest more thanusual.

5. The patient must be told to report immediately if she experiences anysymptoms of heart failure, e.g. worsening shortness of breath or tiredness.

6. The patient must at least be delivered at a secondary level hospital wherespecialist care is available.

7-26 What form of family planning should be offered to patientswith heart valve disease who have completed their families?A postpartum sterilisation should be done. Because of the risk of heartfailure, the procedure must be postponed until the third day after delivery.Patients who are willing and are prepared to return for the procedure, canhave a laparoscopic sterilisation done 6 weeks after delivery. Meanwhile, aninjectable contraceptive must be given.

Diabetes mellitus in pregnancy7-27 Why is it important to diagnose diabetes if it develops inpregnancy?Diabetes mellitus is a disorder which is caused by the secretion of inadequateamounts of insulin from the pancreas to keep the blood glucose concentrationnormal. As a result, the blood glucose concentration becomes abnormally

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high. Diabetes may often present for the first time in pregnancy, and maythen recover spontaneously after delivery. The early diagnosis and goodmanagement of diabetes in pregnancy will greatly reduce the incidence ofcomplications.

7-28 What complications may be caused by diabetes in pregnancy ifit is not diagnosed early and is not well managed?

1. Throughout the pregnancy infections are common, especially:◦ Candida vaginitis.◦ Urinary tract infection.

2. During the first trimester congenital abnormalities may occur in thedeveloping fetus due to the raised blood glucose concentration.

3. During the third trimester pre-eclampsia and polyhydramnios are common.4. The fetus may be large, if the patient’s diabetes has been poorly controlled

during the pregnancy, resulting in problems during labour and deliverymainly:

◦ Cephalopelvic disproportion.◦ Impacted shoulders.

5. During the third stage of labour there is an increased risk of postpartumhaemorrhage.

6. The newborn infant is at increased risk of many complications, especiallyhypoglycaemia and hyaline membrane disease.

7-29 How can complications which commonly occur in diabeticsduring pregnancy and labour be avoided?These complications can largely be avoided by:

1. Early diagnosis.2. Good control of the blood glucose concentration.

Early diagnosis and good control of the blood glucoseconcentration will prevent most of the pregnancy and labourcomplications caused by diabetes.

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7-30 How can diabetes be diagnosed early if it should develop forthe first time during pregnancy?

1. At every antenatal visit all patients should routinely have their urine testedfor glucose.

2. A random blood glucose concentration must be measured if the patient has1+ glycosuria or more at any antenatal visit.

Patients with glycosuria during pregnancy must always beinvestigated further for diabetes.

7-31 Is a reagent strip accurate enough to measure a random bloodglucose concentration?Yes, if an electronic instrument (Glucometer or Reflolux) is used to measurethe blood glucose concentration. A reagent strip alone may not be accurateenough. If an instrument is not available, a sample of blood must be sent tothe nearest laboratory for a blood glucose measurement.

7-32 Is it possible that a patient with an initially normal bloodglucose concentration may develop an abnormal concentrationlater in pregnancy?Yes. This may be possible due to an increase in the amount of placentalhormones as pregnancy progresses. Placental hormones tend to increase theblood glucose concentration, explaining why some patients only becomediabetic during their pregnancies.

7-33 How should random blood glucose measurements beinterpreted and how do the results determine furthermanagement?A random blood glucose measurement is done on a blood sample taken fromthe patient at the clinic without any previous preparation, i.e. the patientdoes not have to fast. However, patients who have had nothing to eat duringthe past 4 hours should be encouraged to eat something before the test.

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1. A random blood glucose concentration of less than 8 mmol/l is normal. Thesepatients can receive routine primary care. However, if glycosuria is againpresent, a random blood glucose measurement must be repeated.

2. A random blood glucose concentration of 8 mmol/l or more, but less than 11mmol/l, may be abnormal and is an indication to measure the fasting bloodglucose concentration. The further management of the patient will depend onthe result of the fasting blood glucose concentration.

3. A random blood glucose concentration of 11 mmol/l or more is abnormal andindicates that the patient has diabetes. These patients must be admitted tohospital to have their blood glucose controlled. Thereafter, they must remainon treatment and be followed as high-risk patients.

7-34 How should fasting blood glucose measurements beinterpreted and how do the results determine furthermanagement?The patient must have nothing to eat or drink (except water) from midnight.At 08:00 the next day a sample of blood is taken and the fasting blood glucoseconcentration is measured:

1. A fasting blood glucose concentration of less than 6 mmol/l is normal. Thesepatients can receive routine primary care. If their random blood glucoseconcentration is again abnormal, the fasting blood glucose concentrationshould be measured again.

2. Patients with fasting blood glucose concentrations of 6 mmol/l or more butless than 8 mmol/l should be placed on a 7600 kilojoule (1800 kilocalorie)diabetic diet. A glucose profile should be determined after 2 weeks and berepeated every 4 weeks until delivery. Usually the glucose profile becomesnormal on this low kilojoule diet.

3. Patients with a fasting blood glucose concentration of 8 mmol/l or more havediabetes. They must be admitted to hospital so that their blood glucoseconcentration can be controlled.

A 7600 kj diabetic diet consists of a normal diet with reduced refinedcarbohydrates (e.g. sugar, cool drinks, fruit juices) and added high fibre foods(e.g. beans and wholewheat bread).

214 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

A patient with a normal blood glucose concentration early inpregnancy may develop diabetes later during that pregnancy.

7-35 How is a glucose profile obtained?The patient must have nothing to eat or drink (except water) from midnight.At 08:00 the next day a sample of blood is taken and the fasting blood glucoseconcentration is measured. Immediately afterwards she has breakfast (whichshe can bring with her to the clinic). After 2 hours the blood glucoseconcentration is measured again.

7-36 How should the glucose profile be interpreted and how do theresults determine further management?

1. A fasting blood glucose result of less than 6 mmol/l and a 2 hour result of lessthan 8 mmol/l are normal. These patients can be followed up as intermediaterisk patients.

2. A fasting blood glucose result of 6 mmol/l or more and/or a 2 hour result of 8mmol/l or more are abnormal. These patients must be admitted to hospital sothat they can have their blood glucose concentration controlled.

DIABETES MELLITUS IN PREGNANCY 215

Figure 7-2: Flow diagram: The management of a patient with glycosuria who hasa random blood glucose concentration measured in pregnancy.

216 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

HIV infection and AIDS in pregnancy7-37 What is AIDS?AIDS is a severe clinical illness caused by the human immunodeficiency virus(HIV). Therefore, severe HIV disease is called AIDS. However, women withHIV infection can remain clinically well for many years before developingsigns of the disease. Patients with AIDS have a damaged immune system.They become infected and often die of other ‘opportunistic infections’ such astuberculosis.

7-38 Is AIDS an important cause of maternal death?As the HIV epidemic spreads, the number of pregnant women dying of AIDShas increased dramatically. In some countries, such as South Africa, AIDS isnow the commonest cause of maternal death.

The Third Report on Confidential Enquiries into Maternal Deaths in SouthAfrica 2002–2004 showed that AIDS was the commonest cause of maternaldeath. Many additional AIDS deaths may have been missed, as HIV testing isoften not done.

AIDS is the commonest cause of maternal death in South Africa.

7-39 Does pregnancy increase the risk of progression fromasymptomatic to symptomatic HIV infection and AIDS?Pregnancy appears to have little or no effect on the progression fromasymptomatic to symptomatic HIV infection. However, in women whoalready have symptomatic HIV infection, pregnancy may lead to a more rapidprogression to AIDS.

The progression of HIV infection during pregnancy can be monitored by:

1. Laboratory tests.2. Clinical signs.

HIV INFECTION AND AIDS IN PREGNANCY 217

7-40 How is the severity of HIV infection classified?1. By assessing the clinical stage of the disease:◦ Stage 1: Clinically well.◦ Stage 2 Mild clinical problems.◦ Stage 3: Moderate clinical problems.◦ Stage 4: Severe clinical problems (ie. AIDS).

2. By measuring the CD4 count in the blood: A falling CD4 count is animportant marker of progression in HIV. It is an indicator of the degree ofdamage to the immune system. A normal CD4 count is 700 to 1100 cells/µl. ACD4 count below 350 cells/µl indicates severe damage to the immune system.

The CD4 count is an important marker of HIV progressionduring pregnancy.

7-41 Can an HIV-positive woman be cared for in a primary careclinic?Most women who are HIV positive are clinically well with a normalpregnancy. Others may only have minor problems (stage 1 or 2). Thesewomen can usually be cared for in a primary care clinic throughout theirpregnancy, labour and puerperium provided their pregnancy is normal.Women with a pregnancy complication should be referred to hospital, aswould be done with HIV-negative patients. Women with severe HIV-relatedproblems (stage 3 or 4) will need to be referred to a special HIV clinic orhospital.

Many HIV-positive women can be managed at a primary careclinic.

7-42 How are pregnant women with HIV infection managed at aprimary care clinic?The management of pregnant women with HIV infection is very similar tothat of non-pregnant adults. The most important step is to identify thosepregnant women who are HIV positive.

218 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

The principles of management of pregnant women with HIV infection at aprimary care clinic are:

1. Make the diagnosis of HIV infection by offering HIV screening to allpregnant women at the start of their antenatal care.

2. Take a history and do a clinical assessment to assess the clinical stage of thediease.

3. Assess the CD4 count in all HIV-positive women as soon as their HIV statusis known.

4. Screen for clinical signs of HIV infection to assess whether the woman hasadvanced to a more severe stage of the disease at each antenatal visit.

5. Good diet. Nutritional support may be needed.6. Emotional support and counselling.7. Prevention of mother-to-child transmission (PMTCT) of HIV.8. Start antiretroviral treatment when indicated.9. Early referral if there are pregnancy or HIV complications.

7-43 Which clinical signs suggest stage 1 and 2 HIV infection?1. Persistent generalised lymphadenopathy is the only clinical sign of stage 1

HIV infection.2. Signs of stage 2 HIV infection include:◦ Mild weight loss (less than 10% of body weight).◦ Repeated or chronic mouth or genital ulcers.◦ Extensive skin rashes.◦ Repeated upper respiratory tract infections such as otitis media or sinusitis.◦ Herpes zoster (shingles).

Most of these women can be managed at a primary care clinic while somemay have to be referred to an HIV clinic for help with treatment. Theseclinical problems are usually treated symptomatically with simple drugswhich are not expensive.

7-44 What are the important features suggesting stage 3 or 4 HIVinfection?

1. Features of stage 3 HIV infection include:◦ Unexplained weight loss (more than 10% of body weight).◦ Oral candidiasis (thrush).◦ Cough, fever and night sweats suggesting pulmonary tuberculosis.

HIV INFECTION AND AIDS IN PREGNANCY 219

◦ Cough, fever and shortness of breath suggesting bacterial pneumonia.◦ Chronic diarrhoea or unexplained fever for more than one month.◦ Pulmonary tuberculosis (TB)

2. Features of stage 4 HIV infection include:◦ Severe weight loss.◦ Severe or repeated bacterial infections, especially pneumonia.◦ Severe HIV associated (opportunistic) infections such as oesophageal

candidiasis (which presents with difficulty swallowing) and Pneumocyctispneumonia (which presents with cough, fever and shortness of breath).

◦ Malignancies such as Kaposi’s sarcoma.◦ Extrapulmonary TB.

7-45 What is antiretroviral treatment?Antiretroviral treatment (i.e. ART or HAART) is the use of three or moreantiretroviral drugs in combination to treat patients with severe HIVinfection. The aim of antiretroviral treatment is to lower the viral load andallow the immune system to recover.

7-46 What are the indications for antiretroviral treatment inpregnancy?The indications for antiretroviral treatment at an HIV clinic are either of thefollowing:

1. Clinical signs of stage 3 or 4 HIV infection.2. A CD4 count below 350 cells/µl.

7-47 What patient preparation is needed for antiretroviraltreatment?Preparing a patient to start antiretroviral treatment is very important. Thisrequires education, counselling and social assessment before antiretroviraltreatment can be started. These patients need to learn about their illness andthe importance of excellent adherence (taking their antiretroviral drugs at thecorrect time every day) and regular clinic attendance. They also need to knowthe side effects of antiretroviral drugs and how to recognise them. Carefulgeneral examination and blood sent for a laboratory hemoglobin

220 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

concentration and liver function test (ALT) are also needed before startingantiretroviral treatment. It usually takes 2 weeks to prepare a patient.

7-48 What drugs are used for starting antiretroviral treatmentduring pregnancy?Usually antiretroviral treatment is provided to pregnant women in SouthAfrica with three drugs:

• D4T 40 mg 12 hourly (or 30 mg 12 hourly in women weighing less than 60 kgor AZT 300 mg 12 hourly.

• 3TC (lamivudine) 150 mg every 12 hours.• Nevirapine 200 mg daily for two weeks followed by 200 mg every 12 hours or

efavirenz (EFV) 600 mg in the evening if the gestational age is more than 12weeks.

This is the current national first line standard drug combination used duringpregnancy. It may change in future.

7-49 What are the side effects of antiretroviral treatment?Pregnant women on antiretroviral treatment may have side effects to thedrugs. These are usually mild and occur during the first 6 weeks of treatment.However, side effects may occur at any time that patients are onantiretroviral treatment. It is important that the staff at primary care clinicsare aware of these side effects and that they ask for symptoms and look forsigns at each clinic visit. Side effects with antiretroviral treatment are morecommon than with antiretroviral prophylaxis during pregnancy.

Common early side effects during the first few weeks of startingantiretroviral treatment include:

1. Lethargy, tiredness and headaches.2. Nausea, vomiting and diarrhoea.3. Muscle pains and weakness.

These mild side effects usually disappear on their own. They can be treatedsymptomatically. It is important that antiretroviral treatment is continuedeven if there are mild side effects.

More severe side effects, which can be fatal, include:

HIV INFECTION AND AIDS IN PREGNANCY 221

1. AZT may suppress the bone marrow causing anaemia. There may also be areduction in the white cell and platelet counts.

2. Severe skin rashes with nevirapine. All patients with severe skin rashes musturgently be referred to the HIV clinic.

3. Hepatitis can be caused by all antiretroviral drugs but especially nevirapine.4. Lactic acidosis is a late but serious side effect, especially with d4T. It presents

with weight loss, tiredness, nausea, vomiting, abdominal pain and shortnessof breath in patients who have been well on antiretroviral treatment for a fewmonths.

Staff at primary care clinics must be aware and look out for these veryimportant side effects.

7-50 How should pregnant women on antiretroviral treatment bemanaged?The national protocol should be followed. It is very important that staff at theantenatal clinic are trained to managed women with HIV infection. Theyshould work together with the local HIV clinic or infectious diseases clinic ofthe local hospital.

Case study 1A patient presents at 30 weeks gestation and complains of backache, feelingfeverish, dysuria and frequency. On examination she has a tachycardia and atemperature of 38.5 °C. A diagnosis of cystitis is made and the patient is givenoral ampicillin to take at home.

1. Do you agree with the diagnosis?No. The symptoms and signs suggest that the patient has acutepyelonephritis.

2. Is the management of this patient adequate to treat acutepyelonephritis?No. The patient should be admitted to hospital and be given a broad-spectrumantibiotic intravenously.

222 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

3. Why is it necessary to treat acute pyelonephritis in pregnancy soaggressively?Because severe complications may occur which can be dangerous both to thepatient and her fetus.

4. What should be done at the first antenatal visit after the patientis discharged from hospital?A midstream urine sample should be collected for culture to make sure thatthe infection has been adequately treated. Her haemoglobin concentrationmust also be measured as patients often become anaemic after acutepyelonephritis.

Case study 2A patient is seen at her first antenatal visit. She is already 36 weeks pregnantand has a haemoglobin concentration of 7.5 g/dl. As she is not short of breathand has no history of antepartum bleeding, she is treated with 2 tablets offerrous suphate to be taken 3 times a day. She is asked to return to the clinicin one week.

1. Do you agree with the management?No. The patient is already 36 weeks pregnant and, therefore, is at great risk ofgoing into labour before her haemoglobin concentration has had time torespond to the oral iron treatment. Therefore, the patient must be admitted tohospital and be given a blood transfusion.

2. Are any further investigations needed?Yes. The cause of the anaemia must always be looked for. Blood for a fullblood count must be taken before she is given a blood transfusion.

CASE STUDY 2 223

3. Is a full blood count adequate to diagnose the cause of theanaemia, or should other investigations be done?In most cases a full blood count is adequate. The majority of patients whohave anaemia without a history of bleeding, are iron deficient. A full bloodcount will confirm the diagnosis of iron deficiency.

4. What should be done if a patient presents before 36 weeksgestation with a haemoglobin concentration below 8 g/dl?If the patient is not short of breath and does not have a tachycardia above 100beats per minute, she may be managed at a high-risk clinic. After blood hasbeen sampled for a full blood count, she should be prescribed 2 ferroussulphate tablets three times a day. With this treatment the patient shouldhave corrected her haemoglobin concentration before she goes into labour.

5. What should be done if a patient presents before 36 weeksgestation with shortness of breath, tachycardia and a lowhaemoglobin concentration?The patient must be admitted to hospital for a blood transfusion. This isnecessary because the patient has shortness of breath and tachycardia whichsuggest heart failure. Again, a full blood count must be done before thetransfusion is started.

Case study 3A patient presents for her first antenatal visit and gives a history that she hasa ‘leaking heart’ due to rheumatic fever as a child. As she has no symptomsand does not get short of breath on exercise, she is reassured and managed asa low-risk patient. As she remains well with no shortness of breath, she istold that she can be delivered by a midwife obstetric unit (primary perinatalcare clinic).

1. Why is the management incorrect?With her history of rheumatic fever and a ‘leaking heart’, the patient must beexamined by a doctor to determine whether she has heart valve disease.

224 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

Undiagnosed heart valve disease can result in serious complications such aspulmonary oedema.

2. What should be done if the patient has a heart murmur due toheart valve disease?The type of heart valve disease must be diagnosed. If the patient needsmedication, the correct drug must be prescribed in the correct dosage. Shemust be managed as a high-risk patient and should be carefully followed upfor symptoms or signs of heart failure.

3. Will most patients with heart valve disease give a history ofprevious rheumatic fever?No. Although most heart valve disease is caused by rheumatic fever duringchildhood, most of these patients are not aware that they have had rheumaticfever.

4. Is it safe to deliver a patient with heart valve disease at a primarycare clinic?No. Special management is needed in at least a secondary hospital withspecialist care available.

Case study 4An obese 35 year old multiparous patient presents with 1+ glycosuria at 20weeks of gestation. At the previous antenatal visit she had no glycosuria. Arandom blood glucose concentration is 7.5 mmol/l. She is reassured andfollowed up as a low-risk patient. At 28 weeks she has 3+ glycosuria. As therandom blood glucose concentration at 20 weeks was normal, she is againreassured and asked to come back to the clinic in 2 weeks.

1. Do you agree with the management at 20 weeks gestation?Yes, the patient was correctly managed when a random blood glucoseconcentration was measured after she had 2+ glycosuria. When 1+ glycosuria

CASE STUDY 4 225

or more is present again, later in pregnancy, a random blood glucoseconcentration must be measured again.

2. How should the patient have been managed at 28 weeks?She should have had another random blood glucose concentrationmeasurement. Further management would depend on the result of this test.

3. Why should a patient be investigated if she has 1+ glycosuria ormore for the first time?The patient may already be a diabetic with a high blood glucoseconcentration causing the glycosuria.

4. What should the management have been if her random bloodglucose was 9.0 mmol/l at 28 weeks gestation?The patient should be seen the next morning after fasting from midnight. Herfasting blood glucose concentration should then be measured.

5. If the patient has a fasting blood glucose concentration of 7.0mmol/l, what should her further management be?The result is abnormal but is not high enough to diagnose diabetes. Sheshould, therefore, be placed on a 7600 kilojoule per day diabetic diet. Aglucose profile must be obtained after 2 weeks and this should be repeatedevery 4 weeks until delivery.

226 MEDICAL PROBLEMS DURING PREGNANCY AND THE PUERPERIUM

Appendix

Guidelines for the management of patientswith risk factors and medical problemsduring pregnancy, labour and thepuerperiumThe following tables list most of the risk factors and medical problems whichmay occur during pregnancy, labour and the puerperium. They also give thepossible adverse effects of these conditions, indicate the actions needed, andsuggest the level of care required. The tables should be read but need not belearned. These tables provide a very useful reference for both midwives anddoctors who are caring for a patients with risk factors.

The following list gives risk factors which may occur during pregnancytogether with their possible adverse effects and assorted problems, andactions which can lead to the prevention, early diagnosis and correctmanagement of complications. The level of care required by the patient isnoted in the last column. The list also serves as a useful guide tomanagement, and can be referred to when risk factors are present or developduring pregnancy. The management of many of the problems is discussed inmore detail elsewhere in the Perinatal Education Programme.

The level of care needed is shown as follows:

• 1 = For low-risk patients• 2 = For intermediate-risk patients• 3 = For high-risk patients

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 227

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Risk factors identified from the patient's history

Maternal age

15 years or less Pregnancy may have adetrimental effect onthe development of thepatient's personality.

Determine the duration of pregnancy. If20 weeks or less termination may beindicated.

2

Poor socialcircumstances.

Refer to social worker for support. Watchfor proteinuria and a rise in bloodpressure from 28 weeks.

Pre-eclampsia.

16-19 years

Anaemia. Regular Hb checks.

1

37 years or more Medical conditionssuch as hypertensionand diabetes arecommoner.

Carefully look for medical problems atthe first visit, and at 28 and 34 weeks.Motivate for sterilisation.

2

37 years or more Chromosomeabnormalities arecommoner, e.g. Downsyndrome

Determine the duration of pregnancy:If 13 weeks or less, an ultrasoundexamination for nuchal thickness isdone, followed at 22 weeks looking forstructural defects.If more than 13 weeks, a geneticamniocentesis should be done between16 and 22 weeks.Before referral, make sure that thepatient will agree to termination ofpregnancy, if this is indicated.

2

228 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

General history

Allergies Penicillin allergy withan anaphylacticreaction is alwaysdangerous, but rarelyoccurs.

Allergies must always be clearlydocumented on the folder and antenatalcard.

1

Cephalopelvicdisproportion andshoulder dystocia.

Ultrasound examination for accurategestational age estimation at 18-22weeks.

Hypertension anddiabetes

Monitor for hypertension and glycosuria.

BMI below 40 1

BMI above 40 but below 50 2

Body Mass Index(BMI)

Use weight, height andattached BMI table.When reading BMI offtable:With 1st visit in 2ndtrimester, subtract 4kgWith 1st visit in 3rdtrimester, subtract 8kg

BMI above 50 3

Diabetes mellitus(in the patient)

Pregnancy worsens thediabetes.Insulin requirementsincrease.Higher incidence offetal death.Large babies withobstructed labour andbirth injuries.Neonatalhypoglycaemia.

Careful control of the diabetes, in orderto keep the blood glucose levels as closeto normal as possible is absolutelyessential.

3

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 229

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Careful screen for glycosuria:

If absent – 1

Diabetes mellitus(family history)

There is an increasedrisk of the patientdeveloping diabetesduring pregnancy.

If present – 2

Epilepsy Convulsions may occurmore frequently inpregnancy. Someanticonvulsant drugsmay cause congenitalabnormalities.

The dose of anticonvulsant drugs mayneed to be increased. Put the patient ona safe drug before pregnancy (e.g.carbamazepine). The drugs are notchanged during pregnancy because ofthe danger of convulsions.

2

Arrange for ultrasound andamniocentesis at 16 weeks:

If normal – 1

Congenitalabnormalities (inthe family)

Serious abnormalitiestend to recur.

If abnormal – 2

Drugs ormedication

Danger ofteratogenesis.Points towards adisease NOTmentioned in thehistory.

Get accurate details and consult adoctor.

1

Join a prevention of mother-to-childtransmission programme.

Refer to an antiretroviral (ARV) clinic forHAART.

1

HIV Mother-to-childtransmission of HIV.With AIDS the mother'sclinical condition maydeteriorate.

The stage of disease needs to bedetermined and noted. Check at eachvisit for symptoms and signs indicatingprogression at a more advanced stage ofdisease.

2

230 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Auto-immunediseases

Raised perinatalmortality rate.Early onset of severepre-eclampsia.

Get detailed information about thedisease and medication.

3

Psychiatric illness Suicide is commoner.Illness may becomeworse duringpregnancy.

Get detailed information about thedisease and medication.Termination of pregnancy may beindicated (if duration of pregnancy is lessthan 20 weeks).

2

Rubella Congenitalabnormalities.

Ask about fever and a skin rash in thefirst trimester of pregnancy and alsoabout contact with rubella.Antibody titres can confirm or excludediagnosis.

1

Thyrotoxicosis(hyperthyroidism)

Thyrotoxicosis and/orgoitre in the neonate.

Get detailed information about theillness and medication. Thyroid hormonelevels in cord blood.

2

Systematic history

Respiratory System

Ask about medication and symptoms:

Asymptomatic and not on steroids – 1

Asthma Prostaglandin F2 alphais contra-indicated.Asthma usuallyimproves duringpregnancy.

Symptomatic and on steroids – 2

Chronic coughmore than 21days. Nightsweats andweight loss.

Possible tuberculosisand/or AIDS.

Single X-ray chest with fetus screened offand sputum for TB bacilli.A rapid test if HIV status unknown.

1

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 231

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Activetuberculosis

Spread to other familymembers and thenewborn infant.

If stable and on treatment. The newborninfant must be given isoniazid.

1

Cardiovascular System

Change to alpha methyldopa and stopdiuretics:

With good control and no proteinuria – 2

Hypertension:1. Diastolic 90mm Hg or more.2.Antihypertensivetreatment.

Pre-eclampsia,abruptio placentae,and IUGR or perinataldeath.

With diastolic 90 mm Hg or more orproteinuria –

3

Dyspnoea andorthopnoea

Symptoms of heartfailure.

Underlying heart disease must beexcluded or confirmed by the doctor.

2

No symptoms or signs of heart failure,and no stenotic heart valve lesions –

2Rheumatic heartdisease

Cardiac outputincreases withincreased risk ofcardiac failure andmaternal death.

Symptoms and signs of heart failure and/or stenotic heart valve lesions –

3

Varicose veins May indicate previousvenous thrombosis.Become worse duringpregnancy.

Watch for possible thrombosis. Bedrestand elastic stockings.

1

Thrombo-embolism

Increased incidence inpregnancy with risk ofmaternal death.

Anticoagulant therapy during pregnancymay have to be considered.

3

Alimentary System

Haemorrhoids May get worse inpregnancy.May prolapse andthrombose.

Only conservative management needed. 1

232 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Test for the hepatitis B antigen:

If antigen absent – 1

Jaundice Danger if the patient isa carrier of thehepatitis B virus.Can infect the infantduring delivery.

If antigen present (the infant must begiven hyperimmune globulin and beimmunised) –

2

HIV positive andon HAART

High risk for seriousliver damage

Stop nevirapine and refer to an ARV clinic 2

Urinary system

Pyelonephritis High risk of recurrence. Midstream urine (MSU) for culture to besure that the infection is completelytreated.

1

Cystitis Common in pregnancy. MSU for culture if symptomatic. 1

Surgical History

Myomectomy Danger of ruptureduterus.

Elective caesarean section indicated. 2

Thyroidectomy Hypothyroidism candevelop duringpregnancy with thedanger of abortion.

If hyperthyroidism was the indication forsurgery, manage as for thyrotoxicosis.Look carefully for an operation scar.Thyroid function tests are indicated.

2

Chest surgery High risk of thrombosisof artificial heart valvesin pregnancy.

Warfarin: danger of teratogenesis in the1st and bleeding in the 3rd trimester.Correct use of anticoagulant therapy.

3

Previous obstetric history

Advise the patient:

Induce labour at 38 weeks. 2

Abruptioplacentae

Tends to recur:10% chance after 1previous abruption.25% chance after 2previous abruptions.

Deliver at 34 weeks, antenatal steroidsfor lung maturity must be given –

3

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 233

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Diabetes mellitus Recurs in successivepregnancies.Complications alreadymentioned.

Random blood glucose if there isglycosuria.

2

Ectopicpregnancy

High risk of recurrence. Gynaecological examination to confirmintra-uterine pregnancy (ultrasound ifuncertain).

1

Grandemultiparity (5 ormore pregnancieshave reachedviability)

Medical conditions arecommoner.Obstetriccomplications arecommoner: IUGR,multiple pregnancy,abnormal lie,obstructed labour andpostpartumhaemorrhage.

Motivate for sterilisation.Look for medical conditions at the firstvisit.Look for abnormal lie after 34 weeks.

2

Infertility Ectopic pregnancy andmultiple pregnancycommoner

Gynaecological examination to confirmintra-uterine pregnancy and the size ofthe uterus. (Ultrasound examination isindicated.)

2

Caesareansection(s)

Danger of ruptureduterus with previousvertical uterineincision, or with two ormore caesariansections.

Get details of the indication and type ofincision from old records.Elective caesarean section at 39 weeks if2 previous caesarean sections or avertical incision.

2

Congenitalabnormalities

Possible geneticinheritance.High risk of recurrence.

Genetic counselling. Amniocentesis andultrasound may be useful.

2

234 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Genetic amniocentesis indicated. 2Abortion More than two firsttrimester abortions.One or more mid-trimester abortions.

If history indicates an incompetentcervix, a MacDonald stitch may beindicated (inserted at 14-16 weeks ).

2

Perinatal death Highest risk group foranother perinataldeath to occur(especially when thecause is unknown).

Get a detailed history and the notes fromthe previous pregnancy.

2

Postpartumhaemorrhage andretained placenta

Tend to recur insuccessivepregnancies.

Deliver in hospital. 2

Low risk of recurrence. 1Pre-eclampsia Two groups:1. Primigravidas withpre-eclampsia close toterm.2. Previous pregnancywith pre-eclampsiadeveloping in late 2ndor early 3rd trimester ofpregnancy.

High risk of recurrence. Low dose aspirin(Disprin) 75 mg daily from 14 weeks.

2

Primigravida Higher incidence ofpre-eclampsia late inpregnancy.

Careful attention to blood pressure andproteinuria.

1

Vacuumextraction orforceps delivery

May indicatecephalopelvicdisproportion.

Careful use of the partogram in labour. 1

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 235

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Preterm labour High risk of arecurrence in the samepregnancy.

Assess the cervix regularly from 26 to 32weeks for changes, more regular bedrest, no intercourse in the second half ofpregnancy. If there is cervicalincompetence, a MacDonald suture maybe indicated.

3

Present obstetric history

If not currently bleeding and there is nofetal distress:1. Do speculum examination:

No local cause. 2

Treatable local cause present. 1

Antepartumhaemorrhage

Abruptio placentae andplacenta praevia areboth seriouscomplications. Localcauses, e.g. vaginitis,cervicitis, can alsocause bleeding. 2. Sonology shows placenta praevia. 3

Asymptomaticbacteriuria

33% incidence ofpyelonephritis in thesepatients.High risk of pretermlabour.

Course of antibiotics.Repeat urine culture at next antenatalvisit.

1

Repeat after 30 minutes rest on her side:

If diastolic 90-99 mmHg withoutproteinuria, start alpha methyl dopa.

2

Diastolic bloodpressure of 90mm Hg or more

Hypertension or pre-eclampsia.

If diastolic 100 mmHg or more orproteinuria, admit to hospital.

2

Duration of pregnancy 28 weeks or more.Repeat kick charts:

Good count without IUGR. 1

Good count with IUGR. 2

Reduced fetalmovements

Fetal distress or intra-uterine death.

If count remains poor, admit to hospital. 2

236 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Random blood glucose estimation:

8 to 11 mmol/l – arrange for fasting bloodglucose estimation.11 mmol/l or more = diabetes.

1

Glycosuria 3+ ormore

Probable diabetes.

Admit to hospital for control if diabetesdiagnosed.

2

Glycosuria 1+ and2+

Possible diabetes. Arrange for random blood glucoseestimation.Less than 8 mm/l is normal.

1

Haemoglobin lessthan 10 g/dl

Anaemia in pregnancy. Arrange full blood count.If confirmed anaemia – Refer.

2

Haematuria Possible cystitis.Bilharzia, if endemic inthe area.

Urine microscopy and culture. Treatcystitis.

1

Regular vaginal examinations from 26weeks for cervical effacement anddilatation.Careful monitoring of proteinuria andrising blood pressure.Do Hb more frequently.Ultrasound examination for growth andchorionicity:

Monochorionic (one placenta) 3

Multiplepregnancy

Greater risk of pretermlabour.High incidence ofperinatal death andpre-eclampsia.Anaemia.

Dichorionic (two placentas) 2

Pyelonephritis incurrentpregnancy

High risk of recurrence. Follow-up urine culture to ensure thattreatment was successful.

2

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 237

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Polyhydramnios Congenitalabnormalities.Multiple pregnancy.Diabetes mellitus.Rh sensitisation maybe present.

Ultrasound examination and randomblood glucose estimation are indicated.Check blood groups, and possiblesensitisation.Exclude oesophageal atresia in the infantimmediately after birth.

2

Exclude urinary tract infection. Test urinefor protein:

Trace (150 mg/l) can be normal. 1

1+ (500 mg/l) and blood pressurenormal.

2

Proteinuria Pre-eclampsia or renaldisease, e.g. chronicnephritis or nephrosis,may be present.

More than 1 + indicates pre-eclampsia orserious kidney disease. Admit tohospital.

2

If 36 weeks or more admit to hospital,wait until the membranes have beenruptured for 6 hours, then induce labourwith oxytocin.

1Rupturedmembranes

Preterm labour andchorioamnionitis.

If 34 weeks or less transfer to level 2hospital.

2

If no antibodies, retest for antibodies at26, 32 and 38 weeks.If antibodies present:

1

Titre less than 1:16. 2

Rhesus negative Rh-sensitisation withhydrops fetalis.

Titre above 1:16 or more. 3

If 34 weeks or more deliver in level 2hospital.

2Preterm labour Preterm infant.

If less than 34 weeks admit to level 3hospital. Consider suppression of labourwith a beta2 stimulant.

3

238 APPENDIX

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

VDRL and FTA/TPHA positive, orVDRL titre 1:16 ormore

Congenital syphilis. Patient must receive full treatment. 1

VDRL titre lessthan 1: 16 andFTA or TPHA notavailable

No history of fulltreatment of womanand partner in past 3months.

Patient must be fully treated. 1

Uterus largerthan dates

Multiple pregnancy.Polyhydramnios.Diabetes.Large fetus.Incorrect dates.

Arrange for sonology and random bloodglucose estimation. With a large fetusthere is a danger of disproportion Beready for shoulder dystocia.

2

Careful measurement of fundal growthand fetal movement counts:

Good growth over a period of 2 weeks. 1

No growth over a period of 2 weeks. 2

Uterus smallerthan dates

IUGR.OligohydramniosFetal death.Incorrect dates.

With few or no fetal movements, admitto hospital.

2

Less than 34 weeks, not important.If more than 34 weeks: exclude thenamed complications, and refer to adoctor for external cephalic version at 36weeks, if there are no contraindications:

Successful version. 2

Abnormal lie Breech, oblique ortransverse lies suggestpossible placentapraevia, multiplepregnancy ordisproportion.

All others. 1

Social history

Alcohol Fetal alcoholsyndrome.

Counselling: no alcohol should be drunkduring pregnancy.

1

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 239

Risk factors Possible adverseeffects duringpregnancy andassociated problems

Action Levelofcare

Religion(Customs)

Fear that certaincustoms will not befulfilled, e.g. withregard to abortions,placenta, etc.

Counselling: Religious beliefs will berespected.

1

Single motherand/or unwantedpregnancy

Complications ofpregnancy arecommoner because ofusually poorer socio-economiccircumstances.

Social support may be needed.Advise about an effective method offamily planning.Sterilisation may be indicated in amultipara.

1

Smoking Danger of IUGR. Advice to the patient: strongly advise herto stop smoking. Encourage her if shestops.Careful attention to fundal growth.

1

Poor socio-economiccircumstances

Pregnancycomplications willoccur more commonly.Malnutrition, infectionand anaemia alsooccur commonly.

Social support necessary.Advise on effective method of familyplanning.Sterilisation may be indicated in amultiparous patient.

1

240 APPENDIX

BMI tableHeight →Weight ↓

140cm

145cm

150cm

155cm

160cm

165cm

170cm

175cm

180cm

185cm

190cm

195cm

200cm

205cm

48 kg 24.5 22.8 21.3 20.0 18.7 17.6 16.6 15.7 14.8 14.0 13.3 12.6 12.0 11.4

51 kg 26.0 24.3 22.7 21.2 19.9 18.7 17.6 16.7 15.7 14.9 14.1 13.4 12.8 12.1

54 kg 27.6 25.7 24.0 22.5 21.1 19.8 18.7 17.6 16.7 15.8 15.0 14.2 13.5 12.8

57 kg 29.1 27.1 25.3 23.7 22.3 20.9 19.7 18.6 17.6 16.7 15.8 15.0 14.3 13.6

60 kg 30.6 28.5 26.7 25.0 23.4 22.0 20.8 19.6 18.5 17.5 16.6 15.8 15.0 14.3

63 kg 32.1 30.0 28.0 26.2 24.6 23.1 21.8 20.6 19.4 18.4 17.5 16.6 15.8 15.0

66 kg 33.7 31.4 29.3 27.5 25.8 24.2 22.8 21.6 20.4 19.3 18.3 17.4 16.5 15.7

69 kg 35.2 32.8 30.7 28.7 27.0 25.3 23.9 22.5 21.3 20.2 19.1 18.1 17.3 16.4

72 kg 36.7 34.2 32.0 30.0 28.1 26.4 24.9 23.5 22.2 21.0 19.9 18.9 18.0 17.1

75 kg 38.3 35.7 33.3 31.2 29.3 27.5 26.0 24.5 23.1 21.9 20.8 19.7 18.8 17.8

78 kg 39.8 37.1 34.7 32.5 30.5 28.7 27.0 25.5 24.1 22.8 21.6 20.5 19.5 18.6

81 kg 41.3 38.5 36.0 33.7 31.6 29.8 28.0 26.4 25.0 23.7 22.4 21.3 20.3 19.3

84 kg 42.9 40.0 37.3 35.0 32.8 30.9 29.1 27.4 25.9 24.5 23.3 22.1 21.0 20.0

87 kg 44.4 41.4 38.7 36.2 34.0 32.0 30.1 28.4 26.9 25.4 24.1 22.9 21.8 20.7

90 kg 45.9 42.8 40.0 37.5 35.2 33.1 31.1 29.4 27.8 26.3 24.9 23.7 22.5 21.4

93 kg 47.4 44.2 41.3 38.7 36.3 34.2 32.2 30.4 28.7 27.2 25.8 24.5 23.3 22.1

96 kg 49.0 45.7 42.7 40.0 37.5 35.3 33.2 31.3 29.6 28.0 26.6 25.2 24.0 22.8

99 kg 50.5 47.1 44.0 41.2 38.7 36.4 34.3 32.3 30.6 28.9 27.4 26.0 24.8 23.6

102 kg 52.0 48.5 45.3 42.5 39.8 37.5 35.3 33.3 31.5 29.8 28.3 26.8 25.5 24.3

105 kg 53.6 49.9 46.7 43.7 41.0 38.6 36.3 34.3 32.4 30.7 29.1 27.6 26.3 25.0

108 kg 55.1 51.4 48.0 45.0 42.2 39.7 37.4 35.3 33.3 31.6 29.9 28.4 27.0 25.7

111 kg 56.6 52.8 49.3 46.2 43.4 40.8 38.4 36.2 34.3 32.4 30.7 29.2 27.8 26.4

114 kg 58.2 54.2 50.7 47.5 44.5 41.9 39.4 37.2 35.2 33.3 31.6 30.0 28.5 27.1

117 kg 59.7 55.6 52.0 48.7 45.7 43.0 40.5 38.2 36.1 34.2 32.4 30.8 29.3 27.8

120 kg 61.2 57.1 53.3 49.9 46.9 44.1 41.5 39.2 37.0 35.1 33.2 31.6 30.0 28.6

GUIDELINES FOR THE MANAGEMENT OF PATIENTS WITH RISK FACTORS AND MEDICAL PROBLEMS DURINGPREGNANCY, LABOUR AND THE PUERPERIUM 241

Height →Weight ↓

140cm

145cm

150cm

155cm

160cm

165cm

170cm

175cm

180cm

185cm

190cm

195cm

200cm

205cm

123 kg 62.8 58.5 54.7 51.2 48.0 45.2 42.6 40.2 38.0 35.9 34.1 32.3 30.8 29.3

126 kg 64.3 59.9 56.0 52.4 49.2 46.3 43.6 41.1 38.9 36.8 34.9 33.1 31.5 30.0

242 BMI TABLE